Basic Information
| Provider Information | |||||||||
| NPI: | 1336337120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOMPOC-ACT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRANSITIONS-MENTAL HEALTH ASSOCIATION | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 277 SOUTH ST | ||||||||
| Address2: | SUITE Y | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934015039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055415144 | ||||||||
| FaxNumber: | 8055419480 | ||||||||
| Practice Location | |||||||||
| Address1: | 646 N H ST | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934364519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058651940 | ||||||||
| FaxNumber: | 8058651954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2007 | ||||||||
| LastUpdateDate: | 07/02/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RICCERI | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8057202655 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | BS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.