=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265406565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEPARTMENT OF STATE HOSPITALS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2006
-----------------------------------------------------
Last Update Date | 10/19/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11401 BLOOMFIELD AVE
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90650-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-863-7011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 O ST # MS -3
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95814-5804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-651-8906
-----------------------------------------------------
Fax | 916-651-8908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DEPUTY DIRECTOR
-----------------------------------------------------
Name | GUADALUPE M ALONZO-DIAZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-654-2655
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 170000832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 170000832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | 170000832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------