Basic Information
Provider Information | |||||||||
NPI: | 1427242213 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SANTA CRUZ COUNTY FOSTER CARE ASO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTH SERVICES AGENCY-MENTAL HEALTH DIVISION | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 EMELINE AVE | ||||||||
Address2: |   | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950601976 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314544170 | ||||||||
FaxNumber: | 8314544663 | ||||||||
Practice Location | |||||||||
Address1: | 1060 EMELINE AVE | ||||||||
Address2: |   | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950601966 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314544170 | ||||||||
FaxNumber: | 8314544663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2007 | ||||||||
LastUpdateDate: | 03/04/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KHALSA | ||||||||
AuthorizedOfficialFirstName: | RAMA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | HEALTH SERVICES AGENCY DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8314544000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF SANTA CRUZ | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
ID | Type | State | Issuer | Description | 44ZZ | 05 | CA |   | MEDICAID | 1659315430 | 01 | CA | LEGAL ENTITY NPI# | OTHER |