1164904108 NPI number — SUN STREET CENTERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164904108 NPI number — SUN STREET CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUN STREET CENTERS
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:
Provider Other Organization Name Type Code:
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:
1164904108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 PEACH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93901-3710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-753-5145
Provider Business Mailing Address Fax Number:
831-753-6005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
637 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KING CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93930-3231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-525-8101
Provider Business Practice Location Address Fax Number:
831-525-8130
Provider Enumeration Date:
09/06/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HORNE
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
CLINICAL SUPERVISOR
Authorized Official Telephone Number:
831-809-8176

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 270003HN . This is a "CA DHCS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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