Provider Demographics
NPI:1922463439
Name:BALTIC SEA MANOR
Entity Type:Organization
Organization Name:BALTIC SEA MANOR
Other - Org Name:N/A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED RCFE
Authorized Official - Phone:925-783-0988
Mailing Address - Street 1:5227 OAKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-6619
Mailing Address - Country:US
Mailing Address - Phone:925-783-0988
Mailing Address - Fax:707-864-1777
Practice Address - Street 1:5227 OAKRIDGE DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-6619
Practice Address - Country:US
Practice Address - Phone:925-783-0988
Practice Address - Fax:707-864-1777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA075601459320700000X
CA075601569320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities