1528068707 NPI number — SOCAL BEHAVIORAL HEALTH PROFESSIONAL CORPORATION

Table of content: (NPI 1528068707)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528068707 NPI number — SOCAL BEHAVIORAL HEALTH PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOCAL BEHAVIORAL HEALTH PROFESSIONAL CORPORATION
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:
6
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:
1528068707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 PARKCENTER DR
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-453-0688
Provider Business Mailing Address Fax Number:
714-453-0691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 PARKCENTER DR
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-453-0688
Provider Business Practice Location Address Fax Number:
714-453-0691
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-453-0688

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  2780787 , 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: LICENSE # 2780787 . This is a "STATE LICENSE #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ65665Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0100750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com