1316438567 NPI number — SUN STREET CENTERS

Table of content: (NPI 1316438567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316438567 NPI number — SUN STREET CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUN STREET CENTERS
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:
SUN STREET CENTERS WOMEN'S RESIDENTIAL PROGRAM HOLLISTER
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:
1316438567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 PEACH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALINAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93901-3710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-809-8176
Provider Business Mailing Address Fax Number:
831-753-6005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
343 6TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLISTER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95023-3834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-265-7317
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/23/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HORNE
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
CLINICAL SUPERVISOR
Authorized Official Telephone Number:
831-809-8176

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  350004BN , 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: 350004BN . This is a "STATE OF CALIFORNIA DEP. OF HEALTH CARE SERVICES" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 303396 . This is a "CARF" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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