1972010650 NPI number — MOUNTAIN SIDE BEHAVIORAL HEALTH LLC

Table of content: (NPI 1972010650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972010650 NPI number — MOUNTAIN SIDE BEHAVIORAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN SIDE BEHAVIORAL HEALTH 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:
1972010650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
70 COLLEGE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95603-5001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-948-4129
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 COLLEGE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95603-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-948-4129
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/04/2018

Additional Information

Authorized Official

Authorized Official Last Name:
ESTRADA
Authorized Official First Name:
AARON
Authorized Official Middle Name:
Authorized Official Title or Position:
COO/PROGRAM DIRECTOR
Authorized Official Telephone Number:
970-948-4129

Provider Taxonomy Codes

  • Taxonomy code: 324500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063779163 . This is a "THIS IS THE MEDICAL DIRECTOR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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