1639223506 NPI number — CCS MEDICAL THERAPY PROGRAM

Table of content: (NPI 1639223506)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639223506 NPI number — CCS MEDICAL THERAPY PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCS MEDICAL THERAPY PROGRAM
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:
1639223506
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:
1800 MT VERNON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSFIELD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-868-0358
Provider Business Mailing Address Fax Number:
661-868-0268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93304-2221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-868-7270
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CONSTANTINE
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PUBLIC HEALTH SERVICES
Authorized Official Telephone Number:
661-868-0301

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X , 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: CCS00107 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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