Healthcare Provider Details

I. General information

NPI: 1205367141
Provider Name (Legal Business Name): NALLS FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 TRAVIS BLVD SUITE 240
FAIRFIELD CA
94533-4897
US

IV. Provider business mailing address

PO BOX 460338
SAN FRANCISCO CA
94146-0338
US

V. Phone/Fax

Practice location:
  • Phone: 707-389-4804
  • Fax:
Mailing address:
  • Phone: 415-505-6427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number487005267
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: TINA DOLLISON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 415-505-6427