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General NPI Number Information
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NPI Number | 1700917515
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Entity Type | Organization
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Legal Business Name | CONNIE'S ICF DD-H
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 02/19/2008
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Provider Practice Location Address
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Address Line | 237 KENT PL
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City | SAN RAMON
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State | CA
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Zip | 94583-3728
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Country | US
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Telephone | 925-829-1938
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Fax | 925-829-1938
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Provider Business Mailing Address
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Address Line | 1117 TANGLEWOOD WAY
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City | SAN MATEO
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State | CA
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Zip | 94403-4919
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Country | US
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Telephone | 650-678-8142
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Fax | 650-638-2590
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CONCEPCION T ANCHETA
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Credential | ADMINISTRATOR
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Telephone | 650-678-8142
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 140000703
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License Number State | CA
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