Provider Demographics
NPI:1942408794
Name:INTEGRATED CARE CENTER
Entity Type:Organization
Organization Name:INTEGRATED CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISRTATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-746-1967
Mailing Address - Street 1:1735 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2417
Mailing Address - Country:US
Mailing Address - Phone:415-746-1940
Mailing Address - Fax:415-746-1941
Practice Address - Street 1:1735 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2417
Practice Address - Country:US
Practice Address - Phone:415-746-1940
Practice Address - Fax:415-746-1941
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAIGHT ASHBURY FREE CLINICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-03
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000486261QP2300X
CA380016ACN261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA380016ACNOtherDADP CERTIFICATION
CA550000486OtherLICENSE
CACMM71176FMedicaid