Basic Information
| Provider Information | |||||||||
| NPI: | 1609098243 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIMI CHILDREN'S PROGRAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1911 WILLIAMS DR | ||||||||
| Address2: | SUITE 210 - BH BILLING | ||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930362612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059815478 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1227 E LOS ANGELES AVE | ||||||||
| Address2: | |||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930652871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055824080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | EGAN | ||||||||
| AuthorizedOfficialFirstName: | NARCISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8056775140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 050000032 | CA | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0000056AX | 05 | CA | MEDICAID |