1528104387 NPI number — COUNTY OF MENDOCINO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528104387 NPI number — COUNTY OF MENDOCINO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF MENDOCINO
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:
SUBSTANCE USE DISORDERS TREATMENT
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:
1528104387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1120 S. DORA STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
UKIAH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95482-6340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-472-2637
Provider Business Mailing Address Fax Number:
707-472-2657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
790 S FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95437-5456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-961-2522
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
JENINE
Authorized Official Middle Name:
Authorized Official Title or Position:
BHRS DEPUTY DIRECTOR
Authorized Official Telephone Number:
707-472-2637

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP0904X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP0905X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2306 . This is a "DRUG MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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