=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497093355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR SOCIAL DYNAMICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2013
-----------------------------------------------------
Last Update Date | 02/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 29TH ST STE 105
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-268-8120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 29TH ST SUITE 105
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-3522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-268-8120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. PETE PALLARES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-309-7981
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------