Provider Demographics
NPI:1447393202
Name:MATEO LODGE, INC.
Entity Type:Organization
Organization Name:MATEO LODGE, INC.
Other - Org Name:POPLAR HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-363-8125
Mailing Address - Street 1:420 CASSIA ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-2011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94061-3013
Practice Address - Country:US
Practice Address - Phone:650-568-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness