Provider Demographics
NPI:1922337864
Name:KAISER PERMANENTE
Entity Type:Organization
Organization Name:KAISER PERMANENTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MFT
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KEPLER HOFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-645-2700
Mailing Address - Street 1:1761 BROADWAY ST
Mailing Address - Street 2:100
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589
Mailing Address - Country:US
Mailing Address - Phone:707-645-2700
Mailing Address - Fax:707-645-2181
Practice Address - Street 1:1761 BROADWAY ST
Practice Address - Street 2:100
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2226
Practice Address - Country:US
Practice Address - Phone:707-645-2700
Practice Address - Fax:707-645-2181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-23
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 47228261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid
CA0=========Medicare NSC