Basic Information
| Provider Information | |||||||||
| NPI: | 1780926964 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TELECARE CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SANTA CRUZ COUNTY PHF | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1080 MARINA VILLAGE PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | ALAMEDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945011078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103377950 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2250 SOQUEL AVE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950621402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316002801 | ||||||||
| FaxNumber: | 8316002820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2013 | ||||||||
| LastUpdateDate: | 01/05/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGFELD | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5103377950 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | Y | Hospitals | Psychiatric Hospital |
ID Information
| ID | Type | State | Issuer | Description | 05-4152 | 01 | CA | MEDICARE PTAN - PART A | OTHER | CA131235 | 01 | CA | MEDICARE PTAN - PART B | OTHER | 054152 | 01 | CA | MEDICARE, OSCAR/CERTIFICATION | OTHER |