=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891082277
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALTERNATIVES TO DOMESTIC VIOLENCE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2011
-----------------------------------------------------
Last Update Date | 07/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4150 LATHAM ST SUITE A
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92501-1735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-320-1370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 910
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92502-0910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | ELIZA WOOLFOLK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-320-1370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------