Basic Information
| Provider Information | |||||||||
| NPI: | 1760685648 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SACRAMENTO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | STOCKTON RETRO - LINX | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7001 EAST PKWY # A | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168754948 | ||||||||
| FaxNumber: | 9168756970 | ||||||||
| Practice Location | |||||||||
| Address1: | 2188 STOCKTON BLVD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168751000 | ||||||||
| FaxNumber: | 9168751002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EDWARDS - BUCKLEY | ||||||||
| AuthorizedOfficialFirstName: | ANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9168759904 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | X | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | X | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 34CY | 05 | CA | MEDICAID |