Basic Information
| Provider Information | |||||||||
| NPI: | 1295109817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CASA PACIFICA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NONE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 LEWIS ROAD | ||||||||
| Address2: | 49 | ||||||||
| City: | CAMIRRILO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930042610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | 8059870258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1021 SCANDIA AVE | ||||||||
| Address2: | 49 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930042473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052481705 | ||||||||
| FaxNumber: | 8059870258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAYWOOD | ||||||||
| AuthorizedOfficialFirstName: | MIZELLA | ||||||||
| AuthorizedOfficialMiddleName: | NONE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 8054457800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 5450 | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ADMINSTRATION | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | MFC29100 | CA | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
No ID Information.