Basic Information
| Provider Information | |||||||||
| NPI: | 1629284609 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANTA CRUZ COUNTY CCS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DUNCAN HOLBERT MTU | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1080 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316228400 | ||||||||
| FaxNumber: | 8317616167 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 HERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950762920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8316888400 | ||||||||
| FaxNumber: | 8317221114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DYBDAHL | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PROGRAM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8317638914 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | CCS00065F | 05 | CA | MEDICAID |