Provider Demographics
NPI:1679868715
Name:FREE AT LAST:COMMUNITY RECOVERY AND REHABILITATION SERVICES
Entity type:Organization
Organization Name:FREE AT LAST:COMMUNITY RECOVERY AND REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-462-6999
Mailing Address - Street 1:1796 BAY RD
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1611
Mailing Address - Country:US
Mailing Address - Phone:650-462-6999
Mailing Address - Fax:650-462-1055
Practice Address - Street 1:1796 BAY RD
Practice Address - Street 2:
Practice Address - City:EAST PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-1611
Practice Address - Country:US
Practice Address - Phone:650-462-6999
Practice Address - Fax:650-462-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410027IN261QR0405X
CA410027AN324500000X
CA410027LN324500000X
CA410027BN324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFREEATLAST11Medicaid