Provider Demographics
NPI:1770944027
Name:HOME AVENUE CTC
Entity type:Organization
Organization Name:HOME AVENUE CTC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AOD COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GACHUPIN
Authorized Official - Suffix:
Authorized Official - Credentials:CATC
Authorized Official - Phone:619-282-8000
Mailing Address - Street 1:3940 HOME AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-5952
Mailing Address - Country:US
Mailing Address - Phone:619-282-8000
Mailing Address - Fax:619-718-9897
Practice Address - Street 1:3940 HOME AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5952
Practice Address - Country:US
Practice Address - Phone:619-282-8000
Practice Address - Fax:619-718-9897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC0502041556261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC0502041556OtherCCAPP