Organization
AVERY LANE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CAMILLE HILDEBRAND (CEO)
(415) 686-6127
Entity
Organization
Contact information
Practice address
2500 VINEYARD RD, NOVATO, CA 94947-3633
(415) 895-5360
Mailing address
505A SAN MARIN DR STE 300, NOVATO, CA 94945-1321
(415) 895-5360
Taxonomy
Speciality
Code
Description
License number
State
324500000X
Substance Abuse Rehabilitation Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
210049DP
DHCS
CA
Enumeration date
06/13/2022
Last updated
06/13/2022
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