Provider Demographics
NPI:1093709206
Name:TIDES CENTERINIC
Entity Type:Organization
Organization Name:TIDES CENTERINIC
Other - Org Name:WOMEN'S COMMUNITY CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLINA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-379-7800
Mailing Address - Street 1:1833 FILLIMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115
Mailing Address - Country:US
Mailing Address - Phone:415-379-7800
Mailing Address - Fax:415-379-7804
Practice Address - Street 1:1833 FILLIMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115
Practice Address - Country:US
Practice Address - Phone:415-379-7800
Practice Address - Fax:415-379-7804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-01
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000401261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70896FMedicaid