Basic Information
| Provider Information | |||||||||
| NPI: | 1508078817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SOLANO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SOLANO COUNTY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 275 BECK AVE MS5 210 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945336804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077848575 | ||||||||
| FaxNumber: | 7074213207 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 COURAGE DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945336717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077842010 | ||||||||
| FaxNumber: | 7074352032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 11/17/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHU | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7077848384 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SOLANO | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QP0905X | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, State or Local | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC11441F | 05 | CA | MEDICAID |