Healthcare Provider Details

I. General information

NPI: 1750110706
Provider Name (Legal Business Name): ODD-FELLOW REBEKAH CHILDREN'S HOME OF CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 W 10TH ST
GILROY CA
95020-6333
US

IV. Provider business mailing address

290 IOOF AVE
GILROY CA
95020-5204
US

V. Phone/Fax

Practice location:
  • Phone: 408-846-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER DANG MALONE
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 408-846-2141