Healthcare Provider Details

I. General information

NPI: 1043249204
Provider Name (Legal Business Name): DEPARTMENT OF STATE HOSPITALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 06/28/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E HIGHLAND AVE
PATTON CA
92369-7813
US

IV. Provider business mailing address

1215 O STREET, MS-3 PATIENT COST RECOVERY SECTION
SACRAMENTO CA
95814-6414
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7552
  • Fax: 909-425-6407
Mailing address:
  • Phone: 916-651-8811
  • Fax: 916-651-8908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number170000831
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number170000831
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number170000831
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number170000831
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number170000831
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number170000831
License Number StateCA

VIII. Authorized Official

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