Basic Information
| Provider Information | |||||||||
| NPI: | 1619041449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF TULARE HEALTH AND HUMAN SERVICES AGENCY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCS PORTERVILLE MTU | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5957 S MOONEY BLVD | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932779394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597374669 | ||||||||
| FaxNumber: | 5597374697 | ||||||||
| Practice Location | |||||||||
| Address1: | 1051 S PLANO ST | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932576026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596852533 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BULLICK | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 5597374669 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | NOT APPLICABLE | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | CCS00110F | 05 | CA | MEDICAID |