Provider Demographics
NPI:1154372498
Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity type:Organization
Organization Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-2282
Mailing Address - Street 1:PO BOX 944202 1215 O STREET MS 10-30
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:94244-2020
Mailing Address - Country:US
Mailing Address - Phone:916-654-3463
Mailing Address - Fax:916-653-4587
Practice Address - Street 1:3530 POMONA BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3238
Practice Address - Country:US
Practice Address - Phone:909-595-1221
Practice Address - Fax:909-595-7252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170000772282N00000X, 313M00000X, 314000000X, 315P00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU661AMedicare PIN
CA050545Medicare Oscar/Certification