Basic Information
Provider Information | |||||||||
NPI: | 1730130097 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CANYON SPRINGS COMMUNITY FACILITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1215 O STREET | ||||||||
Address2: | CFS: MS 10-30 | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 95814 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9166543463 | ||||||||
FaxNumber: | 9166534587 | ||||||||
Practice Location | |||||||||
Address1: | 69696 RAMON RD | ||||||||
Address2: |   | ||||||||
City: | CATHEDRAL CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 922343353 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7607706200 | ||||||||
FaxNumber: | 7603282769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2006 | ||||||||
LastUpdateDate: | 06/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASTANEDA | ||||||||
AuthorizedOfficialFirstName: | CARLA | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF DEPUTY DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9166542822 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 170000774 | CA | N |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   | 333600000X | 170000774 | CA | N |   | Suppliers | Pharmacy |   | 313M00000X | 170000774 | CA | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 315P00000X |   |   | N |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   | 315P00000X | 170000774 | CA | Y |   | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |   |
No ID Information.