=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679710362
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATTON STATE HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2009
-----------------------------------------------------
Last Update Date | 01/16/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3102 E HIGHLAND AVE PROGRAM 4, UNIT 35
-----------------------------------------------------
City | PATTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92369-7813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-425-7363
-----------------------------------------------------
Fax | 909-425-6208
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3102 E HIGHLAND AVE PROGRAM 4, UNIT 35
-----------------------------------------------------
City | PATTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92369-7813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-425-7363
-----------------------------------------------------
Fax | 909-425-6208
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ANDREW J TAMANAHA
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 909-425-7363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number | 21662
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------