1457743957 NPI number — E-ESHORA CCC, INC.

Table of content: (NPI 1457743957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457743957 NPI number — E-ESHORA CCC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E-ESHORA CCC, INC.
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:
1457743957
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1324 MARIGOLD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMPOC
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93436-8204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-743-1515
Provider Business Mailing Address Fax Number:
805-819-0942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 E OCEAN AVE
Provider Second Line Business Practice Location Address:
SUITE 20
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-6937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-743-1515
Provider Business Practice Location Address Fax Number:
805-819-0942
Provider Enumeration Date:
02/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
NEUTZ
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER (CEO)
Authorized Official Telephone Number:
805-743-1515

Provider Taxonomy Codes

  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: CCS #15096 , 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: 1760686489 . This is a "COUNTY OF SANTA BARBARA ALCOHOL/DRUG & MENTAL HEALTH SERVICES MEDI-CAL PROVIDER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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