Basic Information
| Provider Information | |||||||||
| NPI: | 1881002541 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UJIMA FAMILY RECOVERY SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UJIMA WEST OUTPATIENT TREATMENT PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 CHURCH LN | ||||||||
| Address2: | |||||||||
| City: | SAN PABLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948063707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102363139 | ||||||||
| FaxNumber: | 5102363200 | ||||||||
| Practice Location | |||||||||
| Address1: | 12960 SAN PABLO AVE | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948051307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102152280 | ||||||||
| FaxNumber: | 5102152283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2014 | ||||||||
| LastUpdateDate: | 04/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCHANK | ||||||||
| AuthorizedOfficialFirstName: | RITA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5102363139 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UJIMA FAMILY RECOVERY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.