Provider Demographics
NPI:1043249204
Name:DEPARTMENT OF STATE HOSPITALS
Entity type:Organization
Organization Name:DEPARTMENT OF STATE HOSPITALS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALONZO-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-2655
Mailing Address - Street 1:1215 O STREET, MS-3
Mailing Address - Street 2:PATIENT COST RECOVERY SECTION
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6414
Mailing Address - Country:US
Mailing Address - Phone:916-651-8811
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-7552
Practice Address - Fax:909-425-6407
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF STATE HOSPITALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-01
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170000831103TF0200X, 282N00000X, 283Q00000X, 310500000X, 333600000X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes283Q00000XHospitalsPsychiatric Hospital
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensicGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care Hospital
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAR755Medicare PIN
CA05124EMedicare Oscar/Certification