Basic Information
| Provider Information | |||||||||
| NPI: | 1063700656 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANKA BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1850 GATEWAY BLVD | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945208414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258254700 | ||||||||
| FaxNumber: | 8056535974 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 HILLMONT AVENUE | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052337750 | ||||||||
| FaxNumber: | 8056535974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2011 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VYROSTEK | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR QM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9258254700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | D05511203 | AZ | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.