=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376883108
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST COUNTY MENTAL HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2013
-----------------------------------------------------
Last Update Date | 02/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 BROADWAY
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92021-7417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-401-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 590 N PLAZA AMIGO
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92262-6114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-426-0309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | LUZ M. FERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-401-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 669930
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------