Provider Demographics
NPI:1861534190
Name:PORTSMOUTH
Entity type:Organization
Organization Name:PORTSMOUTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:MONES
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:MOHSENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-909-4476
Mailing Address - Street 1:27695 PORTSMOUTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545
Mailing Address - Country:US
Mailing Address - Phone:510-909-4476
Mailing Address - Fax:510-538-7892
Practice Address - Street 1:27695 PORTSMOUTH AVENUE
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545
Practice Address - Country:US
Practice Address - Phone:510-909-4476
Practice Address - Fax:510-538-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHB0022OtherREGION CENTER OF EAST BAY