Healthcare Provider Details

I. General information

NPI: 1942670419
Provider Name (Legal Business Name): BERKELEY ADDICTION TERATMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SACRAMENTO ST
BERKELEY CA
94702-2534
US

IV. Provider business mailing address

2975 SACRAMENTO ST
BERKELEY CA
94702-2534
US

V. Phone/Fax

Practice location:
  • Phone: 510-644-0200
  • Fax:
Mailing address:
  • Phone: 510-644-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number0190
License Number StateCA

VIII. Authorized Official

Name: MARK TISHMAN
Title or Position: FISCAL OFFICER
Credential:
Phone: 510-644-0200