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Organization
EMQ
Active
Organization
EMQ
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CARLOS AGUILA (CLINICAL PROGRAM MANAGER)
(408) 379-9085
Entity
Organization
Contact information
Practice address
251 LLEWELLYN AVE, CAMPBELL, CA 95008-1940
(408) 379-3790
Mailing address
4389 BLOOMFIELD DR, SAN JOSE, CA 95124-4743
(408) 723-1032
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
MFT36007
CA
Other
Enumeration date
11/14/2006
Last updated
08/22/2020
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