Provider Demographics
NPI:1548381262
Name:THE WEST OAKLAND HEALTH COUNCIL
Entity Type:Organization
Organization Name:THE WEST OAKLAND HEALTH COUNCIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:PETTUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-835-9610
Mailing Address - Street 1:700 ADELINE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94607-2608
Mailing Address - Country:US
Mailing Address - Phone:510-835-9610
Mailing Address - Fax:510-272-0209
Practice Address - Street 1:700 ADELINE ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2608
Practice Address - Country:US
Practice Address - Phone:510-835-9610
Practice Address - Fax:510-272-0209
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE WEST OAKLAND HEALTH COUNCIL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-02
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEAP11649FMedicaid