MEDICARE: GEROPHYSCHIATRIC SERVICES, INC

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	320800000X	Mental Illness Community Based Residential Treatment Facility	DMH 02 190 007	CA

General Provider Information

NPI Number	:	1568550390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEROPHYSCHIATRIC SERVICES, INC

Provider Business Mailing Address
First Line	:	1080 MARINA VILLAGE PKWY STE 100
Second Line	:
City	:	ALAMEDA
State	:	CA
Zip	:	94501-1078
Country	:	US
Telephone Number	:	510-337-7950
Fax Number	:	510-337-7969

Provider Business Practice Location Address
First Line	:	6060 N PARAMOUNT BLVD
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90805-3711
Country	:	US
Telephone Number	:	562-634-9534
Fax Number	:	562-634-9534

Authorized Official
Title or Position	:	CFO, SVP
Name	:	LESLIE DAVIS
Credential	:
Telephone Number	:	510-337-7950

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	12/01/2021

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