NPIMap

Organization Active NPI

Peninsula Healthcare Connection, Inc.

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Palo Alto, CA
National Provider Identifier
1295935799
Registry record updated Mar 5, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X
Legal business name
PENINSULA HEALTHCARE CONNECTION, INC.
Practice address
33 Encina Ave
Suite 103
Palo Alto, CA 94301-2300
Phone
(650) 504-6565
Fax
(650) 853-0359
NPI assigned
Jul 23, 2007
Last updated
Mar 5, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 5, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Elfreda E. Strydom
Title
Coo
Phone
(650) 504-6565

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health Clinic/Center (Including Community Mental Health Center) 261QM0801X Primary

Addresses

Primary practice location

33 Encina Ave
Suite 103
Palo Alto, CA 94301-2300

Mailing address

33 Encina Ave
Suite 103
Palo Alto, CA 94301-2300
Phone (650) 504-6565

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20110713000325 CA Part B Supplier - Clinic/Group Practice 3274701545 Receives reassigned benefits from 14 practitioners
Practice locations: Palo Alto, CA
O20220811003384 CA Part A Provider - Federally Qualified Health Center (FQHC) 3274701545 Practice locations: Palo Alto, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1295935799. Details of each certification follow.

Federally qualified health center certification: CCN A01095

Legal name
PENINSULA HEALTHCARE CONNECTION INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 13, 2022
Last certification
Jul 13, 2022
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Enrollment address
33 Encina Ave
Ste 103
Palo Alto, CA 94301-2343

National Provider Directory

National Provider Directory

Locations

33 Encina Ave
Ste 103
Palo Alto, CA 94301
Phone (650) 504-6565

1671 The Alameda
Ste 306
San Jose, CA 95126
Phone (408) 239-4574

Ownership & related parties

All disclosed owners & managing parties 8

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Tom Wasow Individual Corporate Director Oct 1, 2020
Eileen Richardson Individual Corporate Officer Jan 1, 2010
Paul Taylor Individual Corporate Director Oct 1, 2020
Elfreda Strydom Individual Corporate Officer Jul 1, 2010
W-2 Managing Employee Jul 1, 2010
Lisa Douglass Individual Corporate Director Oct 1, 2020
Donald Barr Individual Corporate Director Oct 1, 2020
Melinda Golden Individual Corporate Director Sep 27, 2021
Donna Tversky Individual Corporate Director Oct 1, 2020

Practitioners & affiliated clinicians

Practitioners 30

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 30

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1185148800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1551744000000",
    "number": "1295935799",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "33 ENCINA AVE",
            "address_2": "SUITE 103",
            "city": "PALO ALTO",
            "state": "CA",
            "postal_code": "943012300",
            "telephone_number": "650-504-6565",
            "fax_number": "650-853-0359"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "33 ENCINA AVE",
            "address_2": "SUITE 103",
            "city": "PALO ALTO",
            "state": "CA",
            "postal_code": "943012300",
            "telephone_number": "650-504-6565",
            "fax_number": "650-853-0359"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENINSULA HEALTHCARE CONNECTION, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-23",
        "last_updated": "2019-03-05",
        "status": "A",
        "authorized_official_last_name": "STRYDOM",
        "authorized_official_first_name": "ELFREDA",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "650-504-6565",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Palo Alto, CA

Sources for this page

Verify at the official NPI Registry.