Provider Demographics
NPI:1912063637
Name:ELENA'S ICF DDH #3 INC
Entity Type:Organization
Organization Name:ELENA'S ICF DDH #3 INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUMITRESCU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-785-8137
Mailing Address - Street 1:1162 MERRITT LN
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-2529
Mailing Address - Country:US
Mailing Address - Phone:510-785-8137
Mailing Address - Fax:510-780-9836
Practice Address - Street 1:1162 MERRITT LN
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2529
Practice Address - Country:US
Practice Address - Phone:510-785-8137
Practice Address - Fax:510-780-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000568315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55G196Medicaid