Healthcare Provider Details

I. General information

NPI: 1255474920
Provider Name (Legal Business Name): MATEO LODGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 S HUMBOLDT ST
SAN MATEO CA
94401-2954
US

IV. Provider business mailing address

232 S HUMBOLDT ST
SAN MATEO CA
94401-2954
US

V. Phone/Fax

Practice location:
  • Phone: 650-568-9006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number415600236
License Number StateCA

VIII. Authorized Official

Name: MARY BETH SANDOVAL
Title or Position: CEO
Credential:
Phone: 650-703-3462