Basic Information
| Provider Information | |||||||||
| NPI: | 1972629673 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CASA PACIFICA CENTERS FOR CHILDREN AND FAMILIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 S LEWIS RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930128520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054457800 | ||||||||
| FaxNumber: | 8059877237 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 S MILLER ST | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934551775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059288622 | ||||||||
| FaxNumber: | 8057398863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 05/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | ELSON | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8054457800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | CMM70656F | 05 | CA | MEDICAID | 00275 | 01 | CA | DMH LEGAL ENTITY NUMBER | OTHER |