Basic Information
Provider Information | |||||||||
NPI: | 1902126485 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ENCOMPASS COMMUNITY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CASA PACIFIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 542 OCEAN ST STE K | ||||||||
Address2: |   | ||||||||
City: | SANTA CRUZ | ||||||||
State: | CA | ||||||||
PostalCode: | 950606622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8314590444 | ||||||||
FaxNumber: | 8314590665 | ||||||||
Practice Location | |||||||||
Address1: | 321 E BEACH ST | ||||||||
Address2: |   | ||||||||
City: | WATSONVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 950764801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8312263909 | ||||||||
FaxNumber: | 8314530665 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2010 | ||||||||
LastUpdateDate: | 07/20/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MARTINEZ | ||||||||
AuthorizedOfficialFirstName: | MONICA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8314691700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ENCOMPASS COMMUNITY SERVICES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/20/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 445202230 | CA | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
ID Information
ID | Type | State | Issuer | Description | 445202230 | 01 | CA | DSS - COMMUNITY CARE LICENSING | OTHER |