Basic Information
| Provider Information | |||||||||
| NPI: | 1568550390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GEROPHYSCHIATRIC SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LA CASA MENTAL HEALTH REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | 5103377969 | ||||||||
| Practice Location | |||||||||
| Address1: | 6060 N PARAMOUNT BLVD | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908053711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5626349534 | ||||||||
| FaxNumber: | 5626349534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO, SVP | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | DMH 02 190 007 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.