1629128079 NPI number — EXCEL ACADEMY SHASTA COUNTY MENTAL HEALTH

Table of content: (NPI 1629128079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629128079 NPI number — EXCEL ACADEMY SHASTA COUNTY MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXCEL ACADEMY SHASTA COUNTY MENTAL HEALTH
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:
EXCEL ACADEMY
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:
1629128079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 496048
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDDING
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96049-6048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-225-5200
Provider Business Mailing Address Fax Number:
530-225-5977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3711 OASIS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REDDING
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96003-0397
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-225-5200
Provider Business Practice Location Address Fax Number:
530-225-5977
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONTGOMERY
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF MENTAL HEALTH
Authorized Official Telephone Number:
530-225-5200

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4578 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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