MEDICARE: FIRST PLACE FOR YOUTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253J00000X	Foster Care Agency	487005103	CA

General Provider Information

NPI Number	:	1730538703
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST PLACE FOR YOUTH

Provider Business Mailing Address
First Line	:	426 17TH ST STE 100
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94612-2814
Country	:	US
Telephone Number	:	510-272-0979
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 N TEXAS ST STE 100
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-5623
Country	:	US
Telephone Number	:	510-272-0979
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	SAM COBBS
Credential	:
Telephone Number	:	510-272-0979

Provider Enumeration Date	:	06/09/2016
Last Update Date	:	06/09/2016

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Directions to “FIRST PLACE FOR YOUTH ” Practice Location

Language	Start Address	Practice Location

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