Basic Information
Provider Information | |||||||||
NPI: | 1669503850 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRITTENTON SERVICES FOR CHILDREN AND FAMILIES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CRITTENTON SERVICES FOR CH AND FAM | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 E CHAPMAN AVE | ||||||||
Address2: | SUITE 203 | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928313839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146808268 | ||||||||
FaxNumber: | 7146808207 | ||||||||
Practice Location | |||||||||
Address1: | 100 E VALLEY VIEW DR | ||||||||
Address2: |   | ||||||||
City: | FULLERTON | ||||||||
State: | CA | ||||||||
PostalCode: | 928321321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7146808268 | ||||||||
FaxNumber: | 7146808207 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 09/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CZYPULL | ||||||||
AuthorizedOfficialFirstName: | MANFRED | ||||||||
AuthorizedOfficialMiddleName: | FRITZ | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7146808268 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MIM | ||||||||
NPICertificationDate: | 09/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X |   |   | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |   |
ID Information
ID | Type | State | Issuer | Description | RU 7524 | 01 |   | MEDICAL SITE CERTIFICATION | OTHER |