Organization
A BROADER LIVING EXPERIENCE
Active
Other names
ABLE
Organization subpart
No
Provider details
NPI number
Authorized official
TERRY JONES (BOARD SECRETARY TREASURER)
(415) 492-8087
Entity
Organization
Contact information
Practice address
25 DE ANZA WAY, SAN RAFAEL, CA 94903-3868
(415) 492-8087
(415) 492-0347
Mailing address
25 DE ANZA WAY, SAN RAFAEL, CA 94903-3868
(415) 492-8087
(415) 492-0347
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
LTC60124G
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
LTC60124G
LONG TERM CARE ID
CA
Enumeration date
05/23/2007
Last updated
06/13/2008
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