Basic Information
| Provider Information | |||||||||
| NPI: | 1659695716 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF ORANGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AMHS RECOVERY CENTER NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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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: | 7148346595 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 W LINCOLN AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928052993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145207300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2010 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAJALINGAM | ||||||||
| AuthorizedOfficialFirstName: | CHI | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7148343154 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF ORANGE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PH.D., CHC | ||||||||
| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 30EY | 05 | CA | MEDICAID |