Healthcare Provider Details

I. General information

NPI: 1639223506
Provider Name (Legal Business Name): CCS MEDICAL THERAPY PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 4TH ST
BAKERSFIELD CA
93304-2221
US

IV. Provider business mailing address

1800 MT VERNON AVE
BAKERSFIELD CA
93306
US

V. Phone/Fax

Practice location:
  • Phone: 661-868-7270
  • Fax:
Mailing address:
  • Phone: 661-868-0358
  • Fax: 661-868-0268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. MATTHEW CONSTANTINE
Title or Position: DIRECTOR OF PUBLIC HEALTH SERVICES
Credential:
Phone: 661-868-0301