Provider Demographics
NPI:1215119375
Name:DIAMOND LODGE
Entity type:Organization
Organization Name:DIAMOND LODGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:MAYO
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-577-1004
Mailing Address - Street 1:1135 TOURNAMENT DRIVE
Mailing Address - Street 2:
Mailing Address - City:SF
Mailing Address - State:CA
Mailing Address - Zip Code:94131
Mailing Address - Country:US
Mailing Address - Phone:415-285-0688
Mailing Address - Fax:415-550-6492
Practice Address - Street 1:20 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:SF
Practice Address - State:CA
Practice Address - Zip Code:94131
Practice Address - Country:US
Practice Address - Phone:415-285-0688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness