Healthcare Provider Details

I. General information

NPI: 1063123669
Provider Name (Legal Business Name): CORDILLERAS MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EDMONDS RD
REDWOOD CITY CA
94062-3813
US

IV. Provider business mailing address

1185 HILLCREST BLVD
MILLBRAE CA
94030-2234
US

V. Phone/Fax

Practice location:
  • Phone: 650-367-1890
  • Fax:
Mailing address:
  • Phone: 650-445-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NELIA LASTIMOSA
Title or Position: DIRECTOR OF NURSING
Credential: BSN, RN
Phone: 510-455-6334