MEDICARE: MEN AND WOMEN OF PURPOSE

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	01-005785	CA

General Provider Information

NPI Number	:	1770919946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEN AND WOMEN OF PURPOSE

Provider Business Mailing Address
First Line	:	3029 MACDONALD AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-3010
Country	:	US
Telephone Number	:	510-919-1302
Fax Number	:	855-691-9955

Provider Business Practice Location Address
First Line	:	3029 MACDONALD AVE
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94804-3010
Country	:	US
Telephone Number	:	510-919-1302
Fax Number	:	855-691-9955

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. RICARDO JOSE FORTENBERRY
Credential	:	B.S.H.S. CAS II
Telephone Number	:	510-919-1302

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/19/2013

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Directions to “MEN AND WOMEN OF PURPOSE ” Practice Location

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