Provider Demographics
NPI:1477172864
Name:CALIFORNIA PORTSMOUTH SQUARE ASSOCIATION
Entity Type:Organization
Organization Name:CALIFORNIA PORTSMOUTH SQUARE ASSOCIATION
Other - Org Name:STARLIGHT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:415-574-1213
Mailing Address - Street 1:686 HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-1959
Mailing Address - Country:US
Mailing Address - Phone:510-236-3388
Mailing Address - Fax:
Practice Address - Street 1:686 HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94805-1959
Practice Address - Country:US
Practice Address - Phone:510-236-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253J00000XAgenciesFoster Care Agency
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed ChildrenGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty