MEDICARE: FREDERIC OZANAM CENTER-RAINBOW VILLAGE

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	324500000X	Substance Abuse Rehabilitation Facility	070001LN	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	070001LN	OTHER	CA	DHCS LICENSE

General Provider Information

NPI Number	:	1538607460
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREDERIC OZANAM CENTER-RAINBOW VILLAGE

Provider Business Mailing Address
First Line	:	PO BOX 5487
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94524-0487
Country	:	US
Telephone Number	:	925-798-7250
Fax Number	:	925-798-3359

Provider Business Practice Location Address
First Line	:	2901 PROSPECT AVE
Second Line	:
City	:	CONCORD
State	:	CA
Zip	:	94518-1024
Country	:	US
Telephone Number	:	925-676-4840
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	SUSAN JEANNE CINELLI
Credential	:
Telephone Number	:	925-798-7250

Provider Enumeration Date	:	02/11/2017
Last Update Date	:	02/11/2017

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