Basic Information
| Provider Information | |||||||||
| NPI: | 1982990206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PORTERVILLE DEVELOPMENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 944202 | ||||||||
| Address2: | 1600 9TH STREET ROOM 205 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 942442020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166542431 | ||||||||
| FaxNumber: | 9166543186 | ||||||||
| Practice Location | |||||||||
| Address1: | 26501 AVENUE 140 | ||||||||
| Address2: | |||||||||
| City: | PORTERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932579109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597822222 | ||||||||
| FaxNumber: | 5597825630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2011 | ||||||||
| LastUpdateDate: | 06/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLANNERY | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9166542232 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | 170000837 | CA | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
No ID Information.