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General NPI Number Information
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NPI Number | 1396110219
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Entity Type | Organization
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Legal Business Name | BLACK MOUNTAIN, LLC
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Dates
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Enumeration Date | 12/03/2015
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Last Update Date | 12/03/2015
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Provider Practice Location Address
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Address Line | 177 BOVET RD SUITE 130
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City | SAN MATEO
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State | CA
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Zip | 94402-3116
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Country | US
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Telephone | 650-785-2800
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Fax | 650-785-2801
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Provider Business Mailing Address
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Address Line | PO BOX 72
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City | BURLINGAME
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State | CA
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Zip | 94011-0072
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Country | US
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Telephone | 650-785-2800
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Fax | 650-785-2801
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Authorized Official
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Title or Position | MANAGING DIRECTOR
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Name | JAKE CARUSO
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Credential |
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Telephone | 650-785-2800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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