Basic Information
| Provider Information | |||||||||
| NPI: | 1730130071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AGNEWS DEVELOPMENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 944202 | ||||||||
| Address2: | 1600 9TH STREET | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 942442020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166542431 | ||||||||
| FaxNumber: | 9166543186 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 ZANKER RD | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951342201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4084516198 | ||||||||
| FaxNumber: | 4084516167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/06/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KINSER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9166541963 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 160000519 | CA | N | Hospitals | General Acute Care Hospital | 314000000X | 160000519 | CA | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 313M00000X | 160000519 | CA | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 333600000X | 160000519 | CA | N | Suppliers | Pharmacy | 315P00000X | 160000519 | CA | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.