Basic Information
| Provider Information | |||||||||
| NPI: | 1093085789 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NAPA COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1526 PEAR TREE LN | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586492 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2344 OLD SONOMA RD | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945593708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072534063 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2012 | ||||||||
| LastUpdateDate: | 01/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | BUSTOS-ROJAS | ||||||||
| AuthorizedOfficialFirstName: | GERARDO | ||||||||
| AuthorizedOfficialMiddleName: | ARTURO | ||||||||
| AuthorizedOfficialTitleorPosition: | A & D COUNSELOR III | ||||||||
| AuthorizedOfficialTelephone: | 7072251664 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | CADC II | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 9604139 | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 9604139 | 01 | OR | CADC II | OTHER |