Basic Information
| Provider Information | |||||||||
| NPI: | 1861818593 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOLSOM STREET MEDICAL AND MENTAL HEALTH SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26460 SUMMIT CIR | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913502991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612546630 | ||||||||
| FaxNumber: | 6612546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 10089 FOLSOM BLVD | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956701935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163666531 | ||||||||
| FaxNumber: | 9163666532 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2014 | ||||||||
| LastUpdateDate: | 03/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHARMA | ||||||||
| AuthorizedOfficialFirstName: | STAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6612546630 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 0000 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.