Healthcare Provider Details

I. General information

NPI: 1487986519
Provider Name (Legal Business Name): EMOTIONAL AND BEHAVIORAL HELATH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2010
Last Update Date: 01/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 RANCH RD
COPPEROPOLIS CA
95228
US

IV. Provider business mailing address

PO BOX 189
COPPEROPOLIS CA
95228-0189
US

V. Phone/Fax

Practice location:
  • Phone: 209-785-7766
  • Fax:
Mailing address:
  • Phone: 209-785-7766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number12670
License Number StateCA

VIII. Authorized Official

Name: MR. JOHN TIM ROURKE
Title or Position: OWNER
Credential: PHD
Phone: 209-785-7766