1629079272 NPI number — SPECIALIZED DAYCARE SERVICES, INC

Table of content: MRS. DONNA RACHAEL HORTON STUDENT (NPI 1033645049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629079272 NPI number — SPECIALIZED DAYCARE SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALIZED DAYCARE SERVICES, 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:
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:
1629079272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIR OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95628-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-987-8632
Provider Business Mailing Address Fax Number:
916-989-8635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4811 LAGUNA BLVD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-7043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-987-8632
Provider Business Practice Location Address Fax Number:
916-989-8635
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GIACHINO
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-987-8632

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2065X , with the licence number: 1000001804 , 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: 1629079272 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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