Basic Information
| Provider Information | |||||||||
| NPI: | 1558499749 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRESNO COUNTY CRESTWOOD FRESNO BRIDGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592539180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 153 N U ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937012438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594459094 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | GIANG | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, FRESNO CO. MENTAL HEALTH | ||||||||
| AuthorizedOfficialTelephone: | 5592539180 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 0000010BY | CA | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 0000010BY | 05 | CA | MEDICAID | 2199N | 01 | COST CENTER | OTHER |