Basic Information
Provider Information | |||||||||
NPI: | 1922145143 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF ORANGE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMHS MISSION VIEJO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 405 W 5TH ST STE 212 | ||||||||
Address2: |   | ||||||||
City: | SANTA ANA | ||||||||
State: | CA | ||||||||
PostalCode: | 927014522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7145685614 | ||||||||
FaxNumber: | 7148346595 | ||||||||
Practice Location | |||||||||
Address1: | 23228 MADERO | ||||||||
Address2: |   | ||||||||
City: | MISSION VIEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 926912706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9494543940 | ||||||||
FaxNumber: | 9497701953 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2007 | ||||||||
LastUpdateDate: | 12/20/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RAJALINGAM | ||||||||
AuthorizedOfficialFirstName: | CHI | ||||||||
AuthorizedOfficialMiddleName: | Y. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7148343154 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COUNTY OF ORANGE | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PH.D., CHC | ||||||||
NPICertificationDate: | 12/20/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 8082 | 05 | CA |   | MEDICAID |