Provider Demographics
NPI:1003208281
Name:BAY HORIZON ICF-DDH
Entity Type:Organization
Organization Name:BAY HORIZON ICF-DDH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:PUREZA
Authorized Official - Middle Name:AGUZAR
Authorized Official - Last Name:GANIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-520-5545
Mailing Address - Street 1:1565 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3432
Mailing Address - Country:US
Mailing Address - Phone:650-347-1164
Mailing Address - Fax:650-348-2795
Practice Address - Street 1:516 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3029
Practice Address - Country:US
Practice Address - Phone:650-347-1164
Practice Address - Fax:650-348-2795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000319320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60671GOtherPROVIDER NUMBER