1720299175 NPI number — STATE HEALTH CARE DUAL DIAGNOSIS PROGRAM

Table of content: (NPI 1720299175)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720299175 NPI number — STATE HEALTH CARE DUAL DIAGNOSIS PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE HEALTH CARE DUAL DIAGNOSIS 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:
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:
1720299175
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19300 RINALDI ST
Provider Second Line Business Mailing Address:
SUITE 8270
Provider Business Mailing Address City Name:
NORTHRIDGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91326-1651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-628-9512
Provider Business Mailing Address Fax Number:
818-804-4047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1145 W HEDGES AVE
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93728-1219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-628-9512
Provider Business Practice Location Address Fax Number:
818-804-4047
Provider Enumeration Date:
05/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
EDNA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-628-9512

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X , with the licence number:  100056BP , 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: 1068 . This is a "DMC PROVIDER NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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