Basic Information
| Provider Information | |||||||||
| NPI: | 1265738124 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF MERCED | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | BHRS LOS BANOS ALCOHOL AND DRUG SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2087 | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953440087 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093816800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40 W G ST STE A-E | ||||||||
| Address2: | |||||||||
| City: | LOS BANOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936353657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097106110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 08/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | CRAIG | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093816818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CIPP/US | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.