1053443473 NPI number — PORT CITY OPERATING COMPANY, LLC

Table of content: (NPI 1053443473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053443473 NPI number — PORT CITY OPERATING COMPANY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PORT CITY OPERATING COMPANY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ST. JOSEPH'S BEHAVIORAL HEALTH CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053443473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 213008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95213-9008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-956-4443
Provider Business Mailing Address Fax Number:
209-472-8054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 N CALIFORNIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95204-5502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-948-2100
Provider Business Practice Location Address Fax Number:
209-472-8054
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARTMANN
Authorized Official First Name:
DOREEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
209-467-6442

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  030000367 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ZZZA3902Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 721561125952040001 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: HSP30201J , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 721561125 . This is a "IRS" identifier . This identifiers is of the category "OTHER".
  • Identifier: HSP40201J , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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