Provider Demographics
NPI:1124078704
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:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-651-3238
Mailing Address - Street 1:1215 O ST # MS -3
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-5804
Mailing Address - Country:US
Mailing Address - Phone:916-651-8906
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:24511 W JAYNE AVE
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-9503
Practice Address - Country:US
Practice Address - Phone:559-935-4300
Practice Address - Fax:559-935-7118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X, 310500000X, 333600000X, 283Q00000X
CAHPE471823336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117241OtherPK
ZZZ03708ZMedicare PIN
2117241OtherPK
CA05126EMedicare PIN