Provider Demographics
NPI:1164621454
Name:DAVIS STREET COMMUNITY CENTER
Entity Type:Organization
Organization Name:DAVIS STREET COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FISCAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROSALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-347-4760
Mailing Address - Street 1:3081 TEAGARDEN ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5720
Mailing Address - Country:US
Mailing Address - Phone:510-347-4620
Mailing Address - Fax:510-483-4486
Practice Address - Street 1:3081 TEAGARDEN ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5720
Practice Address - Country:US
Practice Address - Phone:510-347-4620
Practice Address - Fax:510-483-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 39862251S00000X
CAPSY25888251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health