Healthcare Provider Details

I. General information

NPI: 1154372498
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: 01/24/2022
Certification Date: 01/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 POMONA BLVD
POMONA CA
91768-3238
US

IV. Provider business mailing address

PO BOX 944202 1215 O STREET MS 10-30
SACRAMENTO CA
94244-2020
US

V. Phone/Fax

Practice location:
  • Phone: 909-595-1221
  • Fax: 909-595-7252
Mailing address:
  • Phone: 916-654-3463
  • Fax: 916-653-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number170000772
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number170000772
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number170000772
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number170000772
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number170000772
License Number StateCA

VIII. Authorized Official

Name: CARLA CASTANEDA
Title or Position: CHIEF DEPUTY DIRECTOR
Credential:
Phone: 916-654-2282