Healthcare Provider Details

I. General information

NPI: 1104178508
Provider Name (Legal Business Name): BOSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2012
Last Update Date: 10/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 SAN PABLO AVE
OAKLAND CA
94612-1321
US

IV. Provider business mailing address

2280 SAN PABLO AVE
OAKLAND CA
94612-1321
US

V. Phone/Fax

Practice location:
  • Phone: 510-899-4200
  • Fax:
Mailing address:
  • Phone: 510-899-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. MONICA CHAMBERS
Title or Position: TEAM LEADER
Credential: MSW
Phone: 510-899-4207