Provider Demographics
NPI:1902055411
Name:WEST COAST CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:WEST COAST CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:GYN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:510-296-9042
Mailing Address - Street 1:3301 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-3424
Mailing Address - Country:US
Mailing Address - Phone:510-269-9042
Mailing Address - Fax:510-269-9031
Practice Address - Street 1:3301 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3424
Practice Address - Country:US
Practice Address - Phone:510-269-9042
Practice Address - Fax:510-269-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health