1316133705 NPI number — MR. THADDEAUS WAYNE BUSH SR. CATC

Table of content: MR. THADDEAUS WAYNE BUSH SR. CATC (NPI 1316133705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316133705 NPI number — MR. THADDEAUS WAYNE BUSH SR. CATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUSH
Provider First Name:
THADDEAUS
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
CATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUSH
Provider Other First Name:
THADDAEUS
Provider Other Middle Name:
WAYNE
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CATC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1316133705
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/23/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 N. CALIFORNIA ST.
Provider Second Line Business Mailing Address:
SAN JOAQUIN COUNTY BEHAVIORAL HEALTH
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-468-6857
Provider Business Mailing Address Fax Number:
209-468-6739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 W. HOSPITAL RD.
Provider Second Line Business Practice Location Address:
RECOVERY HOUSE
Provider Business Practice Location Address City Name:
FRENCH CAMP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-468-6857
Provider Business Practice Location Address Fax Number:
209-468-6739
Provider Enumeration Date:
09/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  B0411260821 , 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)





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