Basic Information
Provider Information | |||||||||
NPI: | 1033596911 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF MONTEREY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAUREL VISTA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1441 SCHILLING PLACE | ||||||||
Address2: | SOUTH BLDG FLOOR 1 | ||||||||
City: | SALINAS | ||||||||
State: | CA | ||||||||
PostalCode: | 939014527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8317961308 | ||||||||
FaxNumber: | 8317570291 | ||||||||
Practice Location | |||||||||
Address1: | 1441 CONSTITUTION BLVD BLDG 400 | ||||||||
Address2: | SUITE 301 | ||||||||
City: | SALINAS | ||||||||
State: | CA | ||||||||
PostalCode: | 939063100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8317961386 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/30/2015 | ||||||||
LastUpdateDate: | 05/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDGCOMB | ||||||||
AuthorizedOfficialFirstName: | JULIA | ||||||||
AuthorizedOfficialMiddleName: | CLAIRE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR/COO CLINIC SERVICES DIV. | ||||||||
AuthorizedOfficialTelephone: | 8317961386 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MONTEREY COUNTY HEALTH DEPARTMENT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ02040Z | 01 |   | PTAN | OTHER |