Basic Information
Provider Information | |||||||||
NPI: | 1902994783 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GEROPSYCHIATRIC SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LA PAZ GEROPSYCHIATRIC CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1080 MARINA VILLAGE PKWY STE 100 | ||||||||
Address2: |   | ||||||||
City: | ALAMEDA | ||||||||
State: | CA | ||||||||
PostalCode: | 945011078 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5103377950 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 8835 VANS ST | ||||||||
Address2: |   | ||||||||
City: | PARAMOUNT | ||||||||
State: | CA | ||||||||
PostalCode: | 907234656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5626335111 | ||||||||
FaxNumber: | 5626335629 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2006 | ||||||||
LastUpdateDate: | 09/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOPEZ | ||||||||
AuthorizedOfficialFirstName: | LORENA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PROVIDER RELATIONS SUPERVIDOR | ||||||||
AuthorizedOfficialTelephone: | 5102927024 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | LTC#90043F | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.