Basic Information
| Provider Information | |||||||||
| NPI: | 1376730150 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADMHS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 315 CAMINO DEL REMEDIO | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931101332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058841628 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 429 N SAN ANTONIO RD | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058841629 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KWOCK | ||||||||
| AuthorizedOfficialFirstName: | LENNIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8058841629 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | N4473383 | CA | Y | Managed Care Organizations | Exclusive Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | N4473383 | 01 | CA | CALIFORNIA DRIVER LICENSE | OTHER |