Basic Information
| Provider Information | |||||||||
| NPI: | 1780861500 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OASIS BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OASIS COMMUNITY SERVICE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 81557 DOCTOR CARREON BLVD. | ||||||||
| Address2: | SUITE C-8 AND C-9 | ||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922015562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603916999 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 81557 DOCTOR CARREON BLVD. | ||||||||
| Address2: | SUITE C-8 AND C-9 | ||||||||
| City: | INDIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922015562 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603916999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNLAP | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CHIEF EXECUTIVE OFFIC | ||||||||
| AuthorizedOfficialTelephone: | 3102216336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OASIS REHABILITATION CENTER, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 09-00009098 | 01 | CA | CITY OF INDIO BIZ LICENSE | OTHER |