Basic Information
| Provider Information | |||||||||
| NPI: | 1548512635 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TELECARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMHS TAO SOUTH FSP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945016427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | 5103377969 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 EAST BAKER STREET, | ||||||||
| Address2: | SUITE A | ||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926264566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143616760 | ||||||||
| FaxNumber: | 7143616768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 02/27/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | CR722M | 01 | MEDICARE PTAN | OTHER |