Basic Information
| Provider Information | |||||||||
| NPI: | 1386902849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF INYO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | INYO COUNTY HHS-SUD SATELLITE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 380 NORTH MT WHITNEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | LONE PINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 NORTH MT WHITNEY DRIVE | ||||||||
| Address2: | |||||||||
| City: | LONE PINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608736533 | ||||||||
| FaxNumber: | 7608733277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 05/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TURNER | ||||||||
| AuthorizedOfficialFirstName: | JEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH & HUMAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7608736533 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | ZZT11964F | 01 | CA | MEDICAL | OTHER |