Healthcare Provider Details

I. General information

NPI: 1730130097
Provider Name (Legal Business Name): STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/29/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69696 RAMON RD
CATHEDRAL CITY CA
92234-3353
US

IV. Provider business mailing address

1215 O STREET CFS: MS 10-30
SACRAMENTO CA
95814
US

V. Phone/Fax

Practice location:
  • Phone: 760-770-6200
  • Fax: 760-328-2769
Mailing address:
  • Phone: 916-654-3463
  • Fax: 916-653-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number170000774
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number170000774
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number170000774
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number170000774
License Number StateCA

VIII. Authorized Official

Name: CARLA A CASTANEDA
Title or Position: CHIEF DEPUTY DIRECTOR
Credential:
Phone: 916-654-2822