Basic Information
| Provider Information | |||||||||
| NPI: | 1649317116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF ORANGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMHS WESTMINSTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W 5TH ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148345614 | ||||||||
| FaxNumber: | 7148346595 | ||||||||
| Practice Location | |||||||||
| Address1: | 14140 BEACH BLVD | ||||||||
| Address2: | SUITE 200 & 223 | ||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926834453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148967566 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAJALINGAM | ||||||||
| AuthorizedOfficialFirstName: | CHI | ||||||||
| AuthorizedOfficialMiddleName: | Y. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7148343154 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF ORANGE | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D., CHC | ||||||||
| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3009 | 05 | CA | MEDICAID |