=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821200783
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMERICAN STAR HOME 1 ICF/DD-N
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 02/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1209 DAKOTA AVE
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-548-1903
-----------------------------------------------------
Fax | 650-548-1991
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2009 FITZGERALD WAY
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-813-1979
-----------------------------------------------------
Fax | 925-420-6748
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ADMINISTRATOR/ OWNER
-----------------------------------------------------
Name | MRS. VICKY SANTOS TING
-----------------------------------------------------
Credential | BSN
-----------------------------------------------------
Telephone | 925-813-1979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 220000351
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------