Healthcare Provider Details

I. General information

NPI: 1114249364
Provider Name (Legal Business Name): CORDILLERAS MENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2010
Last Update Date: 02/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EDMONDS RD
REDWOOD CITY CA
94062-3813
US

IV. Provider business mailing address

200 EDMONDS RD
REDWOOD CITY CA
94062-3813
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number1063509125
License Number StateCA

VIII. Authorized Official

Name: MS. ARTI R MITHAL
Title or Position: SOCIAL WORKER
Credential: M.A.
Phone: 650-367-1890