1174573802 NPI number — DEPARTMENT OF STATE HOSPITALS

Table of content: (NPI 1174573802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174573802 NPI number — DEPARTMENT OF STATE HOSPITALS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DEPARTMENT OF STATE HOSPITALS
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:
DEPARTMENT OF STATE HOSPITALS-ATASCADERO
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:
1174573802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 O ST # MS -3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95814-5804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-651-8906
Provider Business Mailing Address Fax Number:
916-651-8908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10333 EL CAMINO REAL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATASCADERO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93422-5808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-468-2000
Provider Business Practice Location Address Fax Number:
805-468-6011
Provider Enumeration Date:
05/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALONZO-DIAZ
Authorized Official First Name:
GUADALUPE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATIVE DEPUTY DIRECTOR
Authorized Official Telephone Number:
916-654-2655

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  150000498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 150000498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 310500000X , with the licence number: 150000498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 150000498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 150000498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 150000498 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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