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General NPI Number Information
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NPI Number | 1700050895
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Entity Type | Organization
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Legal Business Name | SUMMERSIDE INC
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Dates
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Enumeration Date | 04/18/2008
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Last Update Date | 04/18/2008
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Provider Practice Location Address
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Address Line | 180 GUAVA CT
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City | VALLEJO
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State | CA
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Zip | 94589-2321
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Country | US
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Telephone | 707-552-7241
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Fax |
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Provider Business Mailing Address
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Address Line | 180 GUAVA CT
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City | VALLEJO
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State | CA
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Zip | 94589-2321
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | EDWARD ANDERSON
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Credential |
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Telephone | 707-552-7241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | LTC60118F
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License Number State | CA
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