Provider Demographics
NPI:1518148857
Name:NEW HAVEN ICF-DDH
Entity Type:Organization
Organization Name:NEW HAVEN ICF-DDH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEONILA
Authorized Official - Middle Name:REALEZA
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-655-3225
Mailing Address - Street 1:100 SAWYER ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2039
Mailing Address - Country:US
Mailing Address - Phone:707-648-2340
Mailing Address - Fax:707-648-1549
Practice Address - Street 1:100 SAWYER ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2039
Practice Address - Country:US
Practice Address - Phone:707-648-2340
Practice Address - Fax:707-648-1549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000133320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60123HOtherMEDICAL PROVIDER NUMBER