Basic Information
| Provider Information | |||||||||
| NPI: | 1295989747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IKERN COUNTY MENTAL HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933021000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618681800 | ||||||||
| FaxNumber: | 6618681801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 N CHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933081770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618681800 | ||||||||
| FaxNumber: | 6618681801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 11/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | MURILLO | ||||||||
| AuthorizedOfficialFirstName: | STACI | ||||||||
| AuthorizedOfficialMiddleName: | MICHELLE | ||||||||
| AuthorizedOfficialTitleorPosition: | CASE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6618681800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 171M00000X | 01 | CA | RECOVERY SPECIUALIST I | OTHER |