=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639179658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIOGENES YOUTH SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9719 LINCOLN VILLAGE DR STE 203
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-369-5447
-----------------------------------------------------
Fax | 916-369-5389
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9719 LINCOLN VILLAGE DR STE 110
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95827-3303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-369-5447
-----------------------------------------------------
Fax | 916-369-5389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. JAMES H BUETO
-----------------------------------------------------
Credential | MPA
-----------------------------------------------------
Telephone | 916-369-5447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 340062AN
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------