=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063942472
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BCT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2017
-----------------------------------------------------
Last Update Date | 06/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1455 GALINDO ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-2899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | (424) 285-4722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1455 GALINDO ST
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94520-2899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | (424) 285-4722
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONSULTANT
-----------------------------------------------------
Name | DEDRICK D WEATHERSBY
-----------------------------------------------------
Credential | M.S., M.ED.
-----------------------------------------------------
Telephone | 424-285-4722
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------