=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063123669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORDILLERAS MENTAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2022
-----------------------------------------------------
Last Update Date | 12/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 EDMONDS RD
-----------------------------------------------------
City | REDWOOD CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94062-3813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-367-1890
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1185 HILLCREST BLVD
-----------------------------------------------------
City | MILLBRAE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94030-2234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-445-3113
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF NURSING
-----------------------------------------------------
Name | NELIA LASTIMOSA
-----------------------------------------------------
Credential | BSN, RN
-----------------------------------------------------
Telephone | 510-455-6334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------