Provider Demographics
NPI:1679004311
Name:SENIOR SUPPORT PROGRAM OF THE TRI-VALLEY
Entity Type:Organization
Organization Name:SENIOR SUPPORT PROGRAM OF THE TRI-VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-931-5395
Mailing Address - Street 1:5353 SUNOL BLVD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-7607
Mailing Address - Country:US
Mailing Address - Phone:925-931-4820
Mailing Address - Fax:
Practice Address - Street 1:5353 SUNOL BLVD
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-7607
Practice Address - Country:US
Practice Address - Phone:925-931-4820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29536253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care