Basic Information
| Provider Information | |||||||||
| NPI: | 1174604367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SACRAMENTO CHILDREN'S HOME | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRANSITIONAL AGE PROGRAM | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2750 SUTTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164927240 | ||||||||
| FaxNumber: | 9167361072 | ||||||||
| Practice Location | |||||||||
| Address1: | 2750 SUTTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164927240 | ||||||||
| FaxNumber: | 9167361072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | MCCARTY | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF COMMUNITY PROGRAMS | ||||||||
| AuthorizedOfficialTelephone: | 9162908140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.