MEDICARE: PUENTES NORTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659315430	OTHER	CA	LEGAL ENTITY NPI#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821133695
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUENTES NORTH

Provider Business Mailing Address
First Line	:	1400 EMELINE AVE
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-1976
Country	:	US
Telephone Number	:	831-454-4170
Fax Number	:	831-454-4663

Provider Business Practice Location Address
First Line	:	115A CORAL ST
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-2104
Country	:	US
Telephone Number	:	831-454-5179
Fax Number	:	831-454-4663

Authorized Official
Title or Position	:	HEALTH SERVICES AGENCY DIRECTOR
Name	:	RAMA KHALSA
Credential	:	PH.D.
Telephone Number	:	831-454-4000

Provider Enumeration Date	:	02/20/2007
Last Update Date	:	03/04/2008

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Directions to “PUENTES NORTH ” Practice Location

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