=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326257577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDENCION A LELCHUK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2691 BEACHWOOD ST
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94545-1239
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-670-0207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27489 PORTSMOUTH AVE
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94545-4014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-670-0207
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REDENCION A LELCHUK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-670-0207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------