Basic Information
| Provider Information | |||||||||
| NPI: | 1326463597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ANKA BEHAVIORAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMADOR TRI-VALLEY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 BUSKIRK AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | PLEASANT HILL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945234343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9258254700 | ||||||||
| FaxNumber: | 9258252610 | ||||||||
| Practice Location | |||||||||
| Address1: | 2177 LAS POSITAS CT STE BC | ||||||||
| Address2: | |||||||||
| City: | LIVERMORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252656160 | ||||||||
| FaxNumber: | 9252948920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2014 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | VYROSTEK | ||||||||
| AuthorizedOfficialFirstName: | GINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR QM MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9258254700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 19200360 | 01 | CA | CCL | OTHER |