Provider Demographics
NPI:1427168673
Name:COUNTY OF CALAVERAS
Entity type:Organization
Organization Name:COUNTY OF CALAVERAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEPUTY DIRECTOR OF HHS
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:LAWLESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-754-2816
Mailing Address - Street 1:891 MOUNTAIN RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9713
Mailing Address - Country:US
Mailing Address - Phone:209-754-6460
Mailing Address - Fax:209-754-6459
Practice Address - Street 1:700 MOUNTAIN RANCH RD
Practice Address - Street 2:C-2
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9707
Practice Address - Country:US
Practice Address - Phone:209-754-6460
Practice Address - Fax:209-754-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA08481507Medicaid