Provider Demographics
NPI:1801526975
Name:AVERY LANE
Entity type:Organization
Organization Name:AVERY LANE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HILDEBRAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-686-6127
Mailing Address - Street 1:505A SAN MARIN DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-1321
Mailing Address - Country:US
Mailing Address - Phone:415-895-5360
Mailing Address - Fax:
Practice Address - Street 1:2500 VINEYARD RD
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-3633
Practice Address - Country:US
Practice Address - Phone:415-895-5360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA210049DPOtherDHCS