Basic Information
| Provider Information | |||||||||
| NPI: | 1154372498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LANTERMAN DEVELOPMENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 944202 1215 O STREET MS 10-30 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 942442020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166543463 | ||||||||
| FaxNumber: | 9166534587 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 POMONA BLVD | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917683238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095951221 | ||||||||
| FaxNumber: | 9095957252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASTANEDA | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9166542282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 170000772 | CA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 170000772 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 315P00000X | 170000772 | CA | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded | 333600000X | 170000772 | CA | N | Suppliers | Pharmacy | 282N00000X | 170000772 | CA | Y | Hospitals | General Acute Care Hospital |
No ID Information.