Provider Demographics
NPI:1316697238
Name:ODD-FELLOW REBEKAH CHILDREN'S HOME OF CA
Entity type:Organization
Organization Name:ODD-FELLOW REBEKAH CHILDREN'S HOME OF CA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DANG
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-591-0043
Mailing Address - Street 1:290 IOOF AVE
Mailing Address - Street 2:
Mailing Address - City:GILROY
Mailing Address - State:CA
Mailing Address - Zip Code:95020-5204
Mailing Address - Country:US
Mailing Address - Phone:408-846-2141
Mailing Address - Fax:
Practice Address - Street 1:21370 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-0203
Practice Address - Country:US
Practice Address - Phone:408-846-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health