Provider Demographics
NPI:1477695377
Name:MATEO LODGE, INC.
Entity Type:Organization
Organization Name:MATEO LODGE, INC.
Other - Org Name:WALLY'S PLACE
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 1:695 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3818
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:695 5TH AVE
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3818
Practice Address - Country:US
Practice Address - Phone:650-568-9006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MATEO LODGE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-14
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410508908320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness