1669812780 NPI number — EL DORADO COMMUNITY SERVICE CENTER

Table of content: (NPI 1669812780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669812780 NPI number — EL DORADO COMMUNITY SERVICE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL DORADO COMMUNITY SERVICE CENTER
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:
MARYSVILLE MEDICAL AND MENTAL HEALTH SERVICES
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:
1669812780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5200 SAN GABRIEL PL
Provider Second Line Business Mailing Address:
STE D
Provider Business Mailing Address City Name:
PICO RIVERA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90660-2497
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-222-1310
Provider Business Mailing Address Fax Number:
562-222-2301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1496 N BEALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYSVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95901-6205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-749-8640
Provider Business Practice Location Address Fax Number:
530-749-8646
Provider Enumeration Date:
07/03/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
SEANJAY
Authorized Official Middle Name:
RAMANAND
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
661-254-6630

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com