Provider Demographics
NPI:1407044209
Name:KATHRYNE MANOR
Entity Type:Organization
Organization Name:KATHRYNE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALERACIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-245-2238
Mailing Address - Street 1:840 KATHRYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3125
Mailing Address - Country:US
Mailing Address - Phone:650-348-5393
Mailing Address - Fax:
Practice Address - Street 1:840 KATHRYNE AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3125
Practice Address - Country:US
Practice Address - Phone:650-348-5393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-06
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities