Basic Information
| Provider Information | |||||||||
| NPI: | 1801056395 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EDGEWOOD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 VICENTE ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941162923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156813211 | ||||||||
| FaxNumber: | 4153757670 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 VICENTE ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941162923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156813211 | ||||||||
| FaxNumber: | 4153757670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2008 | ||||||||
| LastUpdateDate: | 06/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | TATUM | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | TYRONE | ||||||||
| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 4518455073 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 101Y00000X | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.