Basic Information
| Provider Information | |||||||||
| NPI: | 1154413854 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CASA PACIFICA CENTERS FOR CHILDREN AND FAMILIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 S LEWIS RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | 8059877237 | ||||||||
| Practice Location | |||||||||
| Address1: | 1722 S LEWIS RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | 8059877237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | ELSON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | C.E.O | ||||||||
| AuthorizedOfficialTelephone: | 8054457800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 1566-00-01 | CA | N | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness | 261QH0100X | 050000417 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 322D00000X | 1566-00-02 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | CMM70656F | 01 | CA | MEDI-CAL LEGACY NUMBER | OTHER | 050000417 | 01 | CA | DEPT. PUBLIC HEALTH LICENSE | OTHER | 00275 | 01 | CA | DMH LEGAL ENTITY NUMBER | OTHER |