1780721720 NPI number — CCS MEDICAL THERAPY PROGRAM

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 1780721720 NPI number — CCS MEDICAL THERAPY PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCS MEDICAL THERAPY PROGRAM
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:
1780721720
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1800 MT. VERNON AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93306-3302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-868-0306
Provider Business Mailing Address Fax Number:
661-868-0268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1959 PRINCETON ST.
Provider Second Line Business Practice Location Address:
ROOM 33
Provider Business Practice Location Address City Name:
DELANO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93215-1523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-725-6452
Provider Business Practice Location Address Fax Number:
661-725-6170
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONSTANTINE
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PUBLIC HEALTH SERVICES
Authorized Official Telephone Number:
661-868-0301

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , 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: CCS00112F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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