1669546990 NPI number — RAI CARE CENTERS OF NORTHERN CALIFORNIA I, LLC

Table of content: (NPI 1669546990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669546990 NPI number — RAI CARE CENTERS OF NORTHERN CALIFORNIA I, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAI CARE CENTERS OF NORTHERN CALIFORNIA I, LLC
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:
1669546990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
545 E CLEVELAND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95204-5531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-943-0854
Provider Business Mailing Address Fax Number:
209-943-0536

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 E CLEVELAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95204-5531
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-943-0854
Provider Business Practice Location Address Fax Number:
209-943-0536
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLANTON
Authorized Official First Name:
BARRY
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
781-699-9000

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZR0196Z . This is a "BLUE SHIELD OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 04 . This is a "KAISER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 052705 . This is a "BLUE CROSS OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 1669546990 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CDC02705J , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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