Basic Information
| Provider Information | |||||||||
| NPI: | 1043341258 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLORENCE CRITTENTON SERVICES OF ORANGE COUNTY, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRITTENTON SERVICES FOR CHILDREN AND FAMILES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 E CHAPMAN AVE | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928313839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146808265 | ||||||||
| FaxNumber: | 7146808207 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 LONG BEACH BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908072008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146808265 | ||||||||
| FaxNumber: | 7146808207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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| AuthorizedOfficialLastName: | CZYPULL | ||||||||
| AuthorizedOfficialFirstName: | MANFRED | ||||||||
| AuthorizedOfficialMiddleName: | FRITZ | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7146808257 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MIM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | RU 7605 | 01 | CA | MEDICAL SITE CERTIFICATION | OTHER |