Provider Demographics
NPI:1982085981
Name:EXCELLENT CARE PROVIDER INC
Entity Type:Organization
Organization Name:EXCELLENT CARE PROVIDER INC
Other - Org Name:KATHRYNE MANOR ICF/DD-H
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AVELINA
Authorized Official - Middle Name:Q
Authorized Official - Last Name:ALFONSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-255-1072
Mailing Address - Street 1:840 KATHRYNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3125
Mailing Address - Country:US
Mailing Address - Phone:650-703-3532
Mailing Address - Fax:650-583-8224
Practice Address - Street 1:840 KATHRYNE AVE
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3125
Practice Address - Country:US
Practice Address - Phone:650-703-3532
Practice Address - Fax:650-583-8224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000364320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities