Provider Demographics
NPI:1356487532
Name:NBA SERRA RESIDENTIAL CENTER
Entity Type:Organization
Organization Name:NBA SERRA RESIDENTIAL CENTER
Other - Org Name:SERRA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:C
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-876-7302
Mailing Address - Street 1:39055 HASTINGS ST STE 211
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1518
Mailing Address - Country:US
Mailing Address - Phone:510-608-3900
Mailing Address - Fax:510-608-3914
Practice Address - Street 1:39055 HASTINGS ST STE 211
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1518
Practice Address - Country:US
Practice Address - Phone:510-608-3900
Practice Address - Fax:510-608-3914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0200319320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60284FMedicaid