Provider Demographics
NPI:1043628910
Name:HABERCOSS, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:HABERCOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14360 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94579-1134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6955 FOOTHILL BLVD STE 188
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2455
Practice Address - Country:US
Practice Address - Phone:510-388-1768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager