Basic Information
| Provider Information | |||||||||
| NPI: | 1083930788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERIM, INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INTERIM SANDY SHORES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 604 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939403070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316494522 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2982 BAYONET CT | ||||||||
| Address2: | |||||||||
| City: | MARINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939334604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316494522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2010 | ||||||||
| LastUpdateDate: | 08/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8316494522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 27582 | 05 | CA | MEDICAID |