Basic Information
| Provider Information | |||||||||
| NPI: | 1043249204 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF STATE HOSPITALS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | DEPARTMENT OF STATE HOSPITALS - PATTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 O STREET, MS-3 | ||||||||
| Address2: | PATIENT COST RECOVERY SECTION | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958146414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166518811 | ||||||||
| FaxNumber: | 9166518908 | ||||||||
| Practice Location | |||||||||
| Address1: | 3102 E HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | PATTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923697813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094257552 | ||||||||
| FaxNumber: | 9094256407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2006 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALONZO-DIAZ | ||||||||
| AuthorizedOfficialFirstName: | GUADALUPE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9166542655 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF STATE HOSPITALS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TF0200X | 170000831 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Forensic | 282N00000X | 170000831 | CA | N | Hospitals | General Acute Care Hospital | 310500000X | 170000831 | CA | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness | 333600000X | 170000831 | CA | N | Suppliers | Pharmacy | 3336L0003X | 170000831 | CA | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 283Q00000X | 170000831 | CA | Y | Hospitals | Psychiatric Hospital |
No ID Information.