MEDICARE: BEYOND EMANCIPATION TEEN HEALTH CENTER

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	261Q00000X	Clinic/Center	140000704	CA

General Provider Information

NPI Number	:	1821103748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEYOND EMANCIPATION TEEN HEALTH CENTER

Provider Business Mailing Address
First Line	:	2647 INTERNATIONAL BLVD
Second Line	:	SUITE 420
City	:	OAKLAND
State	:	CA
Zip	:	94601-1537
Country	:	US
Telephone Number	:	510-261-4102
Fax Number	:

Provider Business Practice Location Address
First Line	:	2647 INTERNATIONAL BLVD
Second Line	:	SUITE 420
City	:	OAKLAND
State	:	CA
Zip	:	94601-1537
Country	:	US
Telephone Number	:	510-261-4102
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. DAVID PAKTER
Credential	:	MD
Telephone Number	:	510-261-4101

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	06/18/2008

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