MEDICARE: ODD-FELLOW REBEKAH CHILDREN'S HOME OF CA

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1700518933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODD-FELLOW REBEKAH CHILDREN'S HOME OF CA

Provider Business Mailing Address
First Line	:	290 IOOF AVE
Second Line	:
City	:	GILROY
State	:	CA
Zip	:	95020-5204
Country	:	US
Telephone Number	:	408-846-2141
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 LYNG DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95111-2720
Country	:	US
Telephone Number	:	408-846-2100
Fax Number	:

Authorized Official
Title or Position	:	CHIEF COMPLIANCE OFFICER
Name	:	JENNIFER DANG MALONE
Credential	:
Telephone Number	:	408-846-2141

Provider Enumeration Date	:	06/27/2022
Last Update Date	:	06/27/2022

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