Healthcare Provider Details

I. General information

NPI: 1265406565
Provider Name (Legal Business Name): DEPARTMENT OF STATE HOSPITALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 BLOOMFIELD AVE
NORWALK CA
90650-2015
US

IV. Provider business mailing address

1215 O ST # MS -3
SACRAMENTO CA
95814-5804
US

V. Phone/Fax

Practice location:
  • Phone: 562-863-7011
  • Fax:
Mailing address:
  • Phone: 916-651-8906
  • Fax: 916-651-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number170000832
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number170000832
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number170000832
License Number StateCA

VIII. Authorized Official

Name: GUADALUPE M ALONZO-DIAZ
Title or Position: ADMINISTRATIVE DEPUTY DIRECTOR
Credential:
Phone: 916-654-2655