Provider Demographics
NPI:1962759522
Name:CALAVERAS COUNTY
Entity type:Organization
Organization Name:CALAVERAS COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEILY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-754-6516
Mailing Address - Street 1:891 MOUNTAIN RANCH RD
Mailing Address - Street 2:DEPT 127
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:373 WEST ST.CHARLES STREET
Practice Address - Street 2:SUITE B
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249
Practice Address - Country:US
Practice Address - Phone:209-754-6516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000000501Medicaid