=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356374045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAY AREA CONSORTIUM FOR QUALITY HEALTH CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 11/09/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2908 ELLSWORTH ST
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94705-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-843-6194
-----------------------------------------------------
Fax | 510-843-6297
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2908 ELLSWORTH ST
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94705-1912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-843-6194
-----------------------------------------------------
Fax | 510-843-6297
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. GWEN ROWE-LEE SYKES
-----------------------------------------------------
Credential | PH.D
-----------------------------------------------------
Telephone | 510-652-3300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | C41403
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------