=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073368502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDWOOD TEEN CHALLENGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2024
-----------------------------------------------------
Last Update Date | 04/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2844 FAIRFIELD ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-268-8727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1435 7TH ST
-----------------------------------------------------
City | EUREKA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95501-0615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-268-8727
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCE ADMINISTRATOR
-----------------------------------------------------
Name | MARLENE L SIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-268-8727
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174200000X
-----------------------------------------------------
Taxonomy Name | Meals Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 177F00000X
-----------------------------------------------------
Taxonomy Name | Lodging Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------