Basic Information
| Provider Information | |||||||||
| NPI: | 1174573802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DEPARTMENT OF STATE HOSPITALS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DEPARTMENT OF STATE HOSPITALS-ATASCADERO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 O ST # MS -3 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958145804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166518906 | ||||||||
| FaxNumber: | 9166518908 | ||||||||
| Practice Location | |||||||||
| Address1: | 10333 EL CAMINO REAL | ||||||||
| Address2: | |||||||||
| City: | ATASCADERO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934225808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054682000 | ||||||||
| FaxNumber: | 8054686011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALONZO-DIAZ | ||||||||
| AuthorizedOfficialFirstName: | GUADALUPE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9166542655 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF STATE HOSPITALS | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 150000498 | CA | N | Hospitals | General Acute Care Hospital | 310500000X | 150000498 | CA | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mental Illness | 314000000X | 150000498 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 333600000X | 150000498 | CA | N | Suppliers | Pharmacy | 3336L0003X | 150000498 | CA | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 283Q00000X | 150000498 | CA | Y | Hospitals | Psychiatric Hospital |
No ID Information.