Basic Information
| Provider Information | |||||||||
| NPI: | 1134593833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CASA PACIFICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PRIVATE PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 S LEWIS RD | ||||||||
| Address2: | NONE | ||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | 8059870258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1722 LEWIS RD | ||||||||
| Address2: | 268 | ||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930120234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | 8059870258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2015 | ||||||||
| LastUpdateDate: | 11/18/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAMPBELL | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | NONE | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINASTRATION | ||||||||
| AuthorizedOfficialTelephone: | 8054457800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YES | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | MFC2900 | CA | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 3245S0500X | MFC29100 | CA | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 320800000X | MFC29100 | CA | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.