Provider Demographics
NPI:1851833784
Name:CITY OF BERKELEY
Entity Type:Organization
Organization Name:CITY OF BERKELEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-981-5107
Mailing Address - Street 1:3282 ADELINE ST
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2439
Mailing Address - Country:US
Mailing Address - Phone:510-981-5280
Mailing Address - Fax:
Practice Address - Street 1:1521 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-1422
Practice Address - Country:US
Practice Address - Phone:510-981-5280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ80318ZMedicare PIN