Provider Demographics
NPI:1073732673
Name:ANTIOCH ICF, INC
Entity Type:Organization
Organization Name:ANTIOCH ICF, INC
Other - Org Name:PUTNAM ICF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMARIE
Authorized Official - Middle Name:TAMBOT
Authorized Official - Last Name:VERIDIANO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:650-580-2983
Mailing Address - Street 1:2893 EL CAMINO REAL
Mailing Address - Street 2:SUITE C
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94061-4001
Mailing Address - Country:US
Mailing Address - Phone:650-216-9960
Mailing Address - Fax:650-216-9455
Practice Address - Street 1:1204 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-5412
Practice Address - Country:US
Practice Address - Phone:925-755-0910
Practice Address - Fax:925-978-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55G218OtherLONG TERM CARE