Healthcare Provider Details

I. General information

NPI: 1124347000
Provider Name (Legal Business Name): EASTER SEALS NORTHERN CALIFORNIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PIMENTEL CT STE A1
NOVATO CA
94949-5656
US

IV. Provider business mailing address

20 PIMENTEL CT STE A1
NOVATO CA
94949-5656
US

V. Phone/Fax

Practice location:
  • Phone: 415-382-7450
  • Fax: 415-385-7457
Mailing address:
  • Phone: 415-382-7450
  • Fax: 415-385-7457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MARY MARGARET O'BRIEN
Title or Position: DIRECTOR, ACCOUNTING & HUMAN RESOUR
Credential:
Phone: 415-382-7450