MEDICARE: SUPPORTIVE HOUSING COMMUNITY LAND ALLIANCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency

General Provider Information

NPI Number	:	1225893712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE HOUSING COMMUNITY LAND ALLIANCE

Provider Business Mailing Address
First Line	:	3120 SHATTUCK AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-1823
Country	:	US
Telephone Number	:	510-964-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3120 SHATTUCK AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94705-1823
Country	:	US
Telephone Number	:	510-964-9500
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TESLIM IKHARO
Credential	:
Telephone Number	:	510-964-9500

Provider Enumeration Date	:	02/14/2024
Last Update Date	:	02/14/2024

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Directions to “SUPPORTIVE HOUSING COMMUNITY LAND ALLIANCE ” Practice Location

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