Healthcare Provider Details

I. General information

NPI: 1063509123
Provider Name (Legal Business Name): CORDILLERAS MENTAL HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 03/31/2023
Certification Date: 03/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EDMONDS RD
REDWOOD CITY CA
94062-3813
US

IV. Provider business mailing address

1080 MARINA VILLAGE PARKWAY SUITE 100
ALAMEDA CA
94501-1078
US

V. Phone/Fax

Practice location:
  • Phone: 650-367-1890
  • Fax: 650-369-6465
Mailing address:
  • Phone: 510-337-7950
  • Fax: 510-337-7969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberDMH 02 68 015
License Number StateCA

VIII. Authorized Official

Name: LORENA LOPEZ
Title or Position: PROVIDER RELATIONS SUPERVISOR
Credential:
Phone: 510-337-7950