1447775028 NPI number — CAC COLLEGE STREET CENTER

Table of content: (NPI 1447775028)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447775028 NPI number — CAC COLLEGE STREET CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAC COLLEGE STREET CENTER
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:
1447775028
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:
648 N G ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOMPOC
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93436-5360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-737-7272
Provider Business Mailing Address Fax Number:
805-727-7278

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
648 N G ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-5360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-737-7272
Provider Business Practice Location Address Fax Number:
805-727-7278
Provider Enumeration Date:
08/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SCOTT
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
LAUREL
Authorized Official Title or Position:
CLINICAL SERVICES ANALYST
Authorized Official Telephone Number:
805-260-4676

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  28718 , 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: 1457553174 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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