Provider Demographics
NPI:1063558823
Name:COUNTY OF MENDOCINO
Entity type:Organization
Organization Name:COUNTY OF MENDOCINO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUNTLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-472-2607
Mailing Address - Street 1:221 S LENORE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-3632
Mailing Address - Country:US
Mailing Address - Phone:707-456-3821
Mailing Address - Fax:
Practice Address - Street 1:221 S LENORE AVE
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3632
Practice Address - Country:US
Practice Address - Phone:707-456-3821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251K00000XAgenciesPublic Health or Welfare
Not Answered261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
Not Answered261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2302OtherDRUG MEDICAL WILLITS