Healthcare Provider Details

I. General information

NPI: 1801056395
Provider Name (Legal Business Name): EDGEWOOD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 VICENTE ST
SAN FRANCISCO CA
94116-2923
US

IV. Provider business mailing address

1801 VICENTE ST
SAN FRANCISCO CA
94116-2923
US

V. Phone/Fax

Practice location:
  • Phone: 415-681-3211
  • Fax: 415-375-7670
Mailing address:
  • Phone: 415-681-3211
  • Fax: 415-375-7670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number101Y00000X
License Number StateCA

VIII. Authorized Official

Name: CHRISTOPHER TYRONE TATUM
Title or Position: COUNSELOR
Credential:
Phone: 451-845-5073