Basic Information
| Provider Information | |||||||||
| NPI: | 1649413956 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTCARE CALIFORNIA, INC. (CODAC) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4944 E CLINTON WAY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592514800 | ||||||||
| FaxNumber: | 5594536969 | ||||||||
| Practice Location | |||||||||
| Address1: | 4411 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592514800 | ||||||||
| FaxNumber: | 5594536969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2009 | ||||||||
| LastUpdateDate: | 04/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | PIMENTEL | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5592514800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.