Provider Demographics
NPI:1588730642
Name:COUNTY OF MENDOCINO
Entity type:Organization
Organization Name:COUNTY OF MENDOCINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-472-2789
Mailing Address - Street 1:501 LOW GAP RD
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-3738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:860 N BUSH ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3919
Practice Address - Country:US
Practice Address - Phone:707-463-4303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251K00000XAgenciesPublic Health or Welfare
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No291U00000XLaboratoriesClinical Medical Laboratory
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB58594FOtherPH LAB MEDICAL INDENTIFIE
CAZZR11485FOtherPH MEDICAL IDENTIFIER
CA2305OtherAODP DRUG MEDICAL UKIAH
CA2302OtherAODP DRUG MEDICAL WILLITS
CA2306OtherAODP DRUG MEDICAL FTBRAGG
CA00023OtherMH COUNTY MEDICAL IDENTIF
CA2306OtherAODP DRUG MEDICAL FTBRAGG
CAZZR11485FOtherPH MEDICAL IDENTIFIER
CAZZZ74775ZMedicare ID - Type UnspecifiedMH MEDICARE INS GROUP
CA156456Medicare ID - Type UnspecifiedMH MEDICARE RECEIVER
CABBB33295BMedicare ID - Type UnspecifiedMH SUBMITTER NUMBER