Provider Demographics
NPI:1043411762
Name:COUNTY OF STANISLAUS
Entity Type:Organization
Organization Name:COUNTY OF STANISLAUS
Other - Org Name:GENESIS METHADONE
Other - Org Type:Other Name
Authorized Official - Title/Position:BEHAVIORAL HEALTH INTERIM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IMPERIAL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:209-525-6225
Mailing Address - Street 1:800 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-525-6225
Mailing Address - Fax:
Practice Address - Street 1:800 SCENIC DR
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-525-6225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF STANISLAUS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-30
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5014Medicaid