1528068707 NPI number — SOCAL BEHAVIORAL HEALTH PROFESSIONAL CORPORATION

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 1528068707 NPI number — SOCAL BEHAVIORAL HEALTH PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOCAL BEHAVIORAL HEALTH PROFESSIONAL CORPORATION
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:
1528068707
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 PARKCENTER DR
Provider Second Line Business Mailing Address:
SUITE 206
Provider Business Mailing Address City Name:
SANTA ANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92705-3522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-453-0688
Provider Business Mailing Address Fax Number:
714-453-0691

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 PARKCENTER DR
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
SANTA ANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92705-3522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-453-0688
Provider Business Practice Location Address Fax Number:
714-453-0691
Provider Enumeration Date:
07/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-453-0688

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  2780787 , 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: LICENSE # 2780787 . This is a "STATE LICENSE #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ65665Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0100750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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