Healthcare Provider Details

I. General information

NPI: 1265891121
Provider Name (Legal Business Name): ADOLESCENT TREATMENT CENTERS, INC AND THUNDER ROAD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2016
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 40TH ST
OAKLAND CA
94609-2633
US

IV. Provider business mailing address

390 40TH ST
OAKLAND CA
94609-2633
US

V. Phone/Fax

Practice location:
  • Phone: 510-653-5040
  • Fax: 510-653-6475
Mailing address:
  • Phone: 510-653-5040
  • Fax: 510-653-6475

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
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHERINE SVOBODA
Title or Position: SUPERVISOR ADMINISTRATION
Credential:
Phone: 510-653-5040