1629079272 NPI number — SPECIALIZED DAYCARE SERVICES, INC

Table of content: (NPI 1629079272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629079272 NPI number — SPECIALIZED DAYCARE SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPECIALIZED DAYCARE SERVICES, INC
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:
1629079272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIR OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95628-1111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-987-8632
Provider Business Mailing Address Fax Number:
916-989-8635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4811 LAGUNA BLVD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-7043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-987-8632
Provider Business Practice Location Address Fax Number:
916-989-8635
Provider Enumeration Date:
08/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GIACHINO
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-987-8632

Provider Taxonomy Codes

  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385HR2065X , with the licence number: 1000001804 , 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: 1629079272 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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