Basic Information
| Provider Information | |||||||||
| NPI: | 1477193910 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF ORANGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PEI OC CREW | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 W 5TH ST STE 212 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145685614 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4000 W METROPOLITAN DR STE 403 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144805100 | ||||||||
| FaxNumber: | 7149392078 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2020 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAJALINGAM | ||||||||
| AuthorizedOfficialFirstName: | CHI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7148345937 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF ORANGE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3005 | 05 | CA | MEDICAID |