Healthcare Provider Details

I. General information

NPI: 1861638652
Provider Name (Legal Business Name): EDGEWOOD CENTER FOR CHILDREN AND FAMILIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 SEARS ST
SAN FRANCISCO CA
94112-4029
US

IV. Provider business mailing address

131 SEARS ST
SAN FRANCISCO CA
94112-4029
US

V. Phone/Fax

Practice location:
  • Phone: 949-400-4573
  • Fax:
Mailing address:
  • Phone: 949-400-4573
  • Fax:

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

VIII. Authorized Official

Name: MR. JACOB CAYDEN DILLON
Title or Position: RESIDENTIAL COUNSELOR
Credential: BA
Phone: 949-400-4573