Basic Information
| Provider Information | |||||||||
| NPI: | 1861823262 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUCKELEW PROGRAMS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BUCKELEW PROGRAMS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1401 LOS GAMOS DR STE 240 | ||||||||
| Address2: | |||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949031835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153021423 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1109 SIR FRANCIS DRAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | KENTFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949041418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152569995 | ||||||||
| FaxNumber: | 4152569998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2013 | ||||||||
| LastUpdateDate: | 03/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MENSING | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR - QUALITY & COMPLIANCE | ||||||||
| AuthorizedOfficialTelephone: | 4153021423 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 216803488 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.