Basic Information
| Provider Information | |||||||||
| NPI: | 1689762486 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TELECARE CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TELECARE MCMILLAN RANCH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | |||||||||
| Practice Location | |||||||||
| Address1: | 3840 ORCUTT GAREY RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934549629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059378286 | ||||||||
| FaxNumber: | 8059372296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/06/2017 | ||||||||
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| 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 | DDS 425808215 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.