Basic Information
Provider Information | |||||||||
NPI: | 1497397665 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENVIRONMENTAL ALTERNATIVES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EA FAMILY SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3940 | ||||||||
Address2: |   | ||||||||
City: | QUINCY | ||||||||
State: | CA | ||||||||
PostalCode: | 959713940 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1229 BROADWAY | ||||||||
Address2: |   | ||||||||
City: | RICHVALE | ||||||||
State: | CA | ||||||||
PostalCode: | 95974 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5308824125 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2019 | ||||||||
LastUpdateDate: | 07/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KING | ||||||||
AuthorizedOfficialFirstName: | MELODY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5302833330 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ENVIRONMENTAL ALTERNATIVES BUTTE VALLEY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X |   |   | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
ID Information
ID | Type | State | Issuer | Description | 045002532 | 01 | CA | COMMUNITY CARE LICENSING | OTHER |