1194971473 NPI number — JANUS OF SANTA CRUZ

Table of content: (NPI 1194971473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194971473 NPI number — JANUS OF SANTA CRUZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANUS OF SANTA CRUZ
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:
MONDANARO-BASKIN CENTER FOR WOMEN AND CHILDREN
Provider Other Organization Name Type Code:
5
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:
1194971473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 7TH AVENUE
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95062-4668
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-462-1060
Provider Business Mailing Address Fax Number:
831-462-4970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 CHESTNUT ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA CRUZ
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95060-3669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-423-9015
Provider Business Practice Location Address Fax Number:
831-423-9098
Provider Enumeration Date:
08/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMS
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
831-278-7906

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  440003DN , 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: 4496 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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