Provider Demographics
NPI:1407109986
Name:COUNTY OF ALAMEDA HEALTH CARE SERVICES AGENCY
Entity Type:Organization
Organization Name:COUNTY OF ALAMEDA HEALTH CARE SERVICES AGENCY
Other - Org Name:TRUST CLINIC -- ALAMEDA COUNTY HEALTH CARE FOR THE HOMELESS PROGRAM
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:W
Authorized Official - Last Name:MODERSBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-532-1930
Mailing Address - Street 1:1900 FRUITVALE AVE STE 3E
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2469
Mailing Address - Country:US
Mailing Address - Phone:510-532-1930
Mailing Address - Fax:510-532-0963
Practice Address - Street 1:384 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3211
Practice Address - Country:US
Practice Address - Phone:510-532-1930
Practice Address - Fax:510-532-0963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407109986Medicaid