1235464496 NPI number — LAKE COUNTY COMMUNITY ACTION AGENCY

Table of content: (NPI 1235464496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235464496 NPI number — LAKE COUNTY COMMUNITY ACTION AGENCY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE COUNTY COMMUNITY ACTION AGENCY
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:
1235464496
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15312 LAKESHORE DRIVE
Provider Second Line Business Mailing Address:
PO BOX 969
Provider Business Mailing Address City Name:
CLEARLAKE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-995-2920
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15850 A DAM ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARLAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-994-6447
Provider Business Practice Location Address Fax Number:
707-994-1875
Provider Enumeration Date:
10/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LEHNE
Authorized Official First Name:
GEORGINA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
707-995-2920

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  170010BN , 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: 014651850 . This is a "COMMUNITY BEHAVIORAL HEALTH" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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