1225259179 NPI number — COMMUNITY SUPPORT NETWORK

Table of content: (NPI 1225259179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225259179 NPI number — COMMUNITY SUPPORT NETWORK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY SUPPORT NETWORK
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:
CSN SAIL
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:
1225259179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 GUERNEVILLE RD
Provider Second Line Business Mailing Address:
SUITE #14
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-575-0979
Provider Business Mailing Address Fax Number:
707-573-6968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
634 PRESSLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-477-2521
Provider Business Practice Location Address Fax Number:
707-573-6968
Provider Enumeration Date:
05/01/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEVITT
Authorized Official First Name:
ROSEMARY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
707-575-0979

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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