Provider Demographics
NPI:1003249657
Name:TIDES CENTER
Entity Type:Organization
Organization Name:TIDES CENTER
Other - Org Name:ADOLESCENT HEALTH WORKING GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ'G
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:415-236-1166
Mailing Address - Street 1:1008 GENERAL KENNEDY AVE
Mailing Address - Street 2:SUITE R
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94129-1729
Mailing Address - Country:US
Mailing Address - Phone:415-236-1166
Mailing Address - Fax:
Practice Address - Street 1:1008 GENERAL KENNEDY AVE
Practice Address - Street 2:SUITE R
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94129-1729
Practice Address - Country:US
Practice Address - Phone:415-236-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIDES CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-19
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization