=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942584354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAN JOAQUIN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2011
-----------------------------------------------------
Last Update Date | 10/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 MICHAEL CANLIS WAY
-----------------------------------------------------
City | FRENCH CAMP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95231-9781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-468-5129
-----------------------------------------------------
Fax | 209-468-5184
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7000 MICHAEL CANLIS WAY
-----------------------------------------------------
City | FRENCH CAMP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95231-9781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-468-5129
-----------------------------------------------------
Fax | 209-468-5184
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SENIOR PSYCHIATRIC TECHNICIAN
-----------------------------------------------------
Name | BELINDA GRAHAM
-----------------------------------------------------
Credential | SPT
-----------------------------------------------------
Telephone | 209-468-5129
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310500000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Intermediate Care Facility
-----------------------------------------------------
License Number | PT30322
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------