Provider Demographics
NPI:1063509123
Name:CORDILLERAS MENTAL HEALTH CORPORATION
Entity Type:Organization
Organization Name:CORDILLERAS MENTAL HEALTH CORPORATION
Other - Org Name:CORDILLERAS MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER RELATIONS SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-337-7950
Mailing Address - Street 1:1080 MARINA VILLAGE PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1078
Mailing Address - Country:US
Mailing Address - Phone:510-337-7950
Mailing Address - Fax:510-337-7969
Practice Address - Street 1:200 EDMONDS RD
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-3813
Practice Address - Country:US
Practice Address - Phone:650-367-1890
Practice Address - Fax:650-369-6465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADMH 02 68 015320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR18511GOtherMEDICAID