Basic Information
| Provider Information | |||||||||
| NPI: | 1487166120 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SAMARITAN SHELTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TRANSITIONAL CENTER FOR WOMEN AND CHILDREN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 412 EAST TUNNELL STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059250315 | ||||||||
| FaxNumber: | 8665947933 | ||||||||
| Practice Location | |||||||||
| Address1: | 412 EAST TUNNELL STREET | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059250315 | ||||||||
| FaxNumber: | 8665947933 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2017 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | DONNA | ||||||||
| AuthorizedOfficialMiddleName: | MICHELL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF TREATMENT | ||||||||
| AuthorizedOfficialTelephone: | 8052663747 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GOOD SAMARITAN SHELTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CADTP/CAODC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.