Provider Demographics
NPI:1366645293
Name:WESTCOAST CHILDREN'S CLINIC
Entity type:Organization
Organization Name:WESTCOAST CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF QA AND COMPLIANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:NEWTON
Authorized Official - Last Name:GROSU
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-269-9148
Mailing Address - Street 1:PO BOX 7026
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-0026
Mailing Address - Country:US
Mailing Address - Phone:510-269-9030
Mailing Address - Fax:510-269-9031
Practice Address - Street 1:3301 E. 12TH STREET STE 259
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-2940
Practice Address - Country:US
Practice Address - Phone:510-269-9030
Practice Address - Fax:510-269-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA020000193251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01DWOtherMEDI-CAL PROVIDER NUMBER