1801930920 NPI number — SOUTH COUNTY MENTAL HEALTH

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 1801930920 NPI number — SOUTH COUNTY MENTAL HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COUNTY MENTAL HEALTH
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:
1801930920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 EMELINE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA CRUZ
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95060-1976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-454-4971
Provider Business Mailing Address Fax Number:
831-454-4663

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1430 FREEDOM BLVD
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
WATSONVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95076-2780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-763-8200
Provider Business Practice Location Address Fax Number:
831-454-4663
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RANDOLPH
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF ADMINISTRATION
Authorized Official Telephone Number:
831-454-4000

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , 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: 1659315430 . This is a "LEGAL ENTITY NPI#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ91891Z . This is a "COUNTY OF SANTA CRUZ MEDICARE GROUP PTAN#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 4475 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: FHC70044F . This is a "SANTA CRUZ COUNTY MEDI-CAL GROUP NUNMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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