Provider Demographics
NPI:1366818031
Name:AGESONG INC
Entity Type:Organization
Organization Name:AGESONG INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MFT INTERN
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:MFT TRAINEE
Authorized Official - Phone:209-403-3748
Mailing Address - Street 1:3121 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-2112
Mailing Address - Country:US
Mailing Address - Phone:209-403-3748
Mailing Address - Fax:
Practice Address - Street 1:3121 FRUITVALE AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94602-2112
Practice Address - Country:US
Practice Address - Phone:209-403-3748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AGESONG INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-18
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness