Basic Information
| Provider Information | |||||||||
| NPI: | 1649601550 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JANUS OF SANTA CRUZ | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY CLINIC SOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 200 7TH AVENUE | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950624668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314621060 | ||||||||
| FaxNumber: | 8314624970 | ||||||||
| Practice Location | |||||||||
| Address1: | 284 PENNSYLVANIA DR STE 1&2 | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950763768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313194200 | ||||||||
| FaxNumber: | 8313194204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2013 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | AMBER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8312787906 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 44-06 | CA | N | Agencies | Community/Behavioral Health | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM2800X | 4405 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 44AB | 05 | CA | MEDICAID | 44AC | 05 | CA | MEDICAID |