1588615835 NPI number — STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES

Table of content: (NPI 1588615835)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588615835 NPI number — STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
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:
PORTERVILLE DEVELOPMENTAL CENTER
Provider Other Organization Name Type Code:
5
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:
1588615835
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1215 O STREET
Provider Second Line Business Mailing Address:
CFS: MS 10-30
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-654-3463
Provider Business Mailing Address Fax Number:
916-653-4587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26501 AVENUE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93257-9109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-782-2222
Provider Business Practice Location Address Fax Number:
559-782-5630
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CASTANEDA
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF DEPUTY DIRECTOR
Authorized Official Telephone Number:
916-654-2822

Provider Taxonomy Codes

  • Taxonomy code: 282E00000X , with the licence number:  40000188 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 40000188 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 313M00000X , with the licence number: 40000188 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 40000188 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 315P00000X , with the licence number: 40000188 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 40000188 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: HPE19554 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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