Provider Demographics
NPI:1053443473
Name:PORT CITY OPERATING COMPANY, LLC
Entity Type:Organization
Organization Name:PORT CITY OPERATING COMPANY, LLC
Other - Org Name:ST. JOSEPH'S BEHAVIORAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOREEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-467-6442
Mailing Address - Street 1:PO BOX 213008
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95213-9008
Mailing Address - Country:US
Mailing Address - Phone:209-956-4443
Mailing Address - Fax:209-472-8054
Practice Address - Street 1:2510 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5502
Practice Address - Country:US
Practice Address - Phone:209-948-2100
Practice Address - Fax:209-472-8054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PORT CITY OPERATING COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-12
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000367283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZA3902ZOtherBLUE SHIELD
721561125952040001OtherTRICARE
CAHSP30201JMedicaid
721561125OtherIRS
CAHSP40201JMedicaid
ZZZA3902ZOtherBLUE SHIELD
CA054123Medicare Oscar/Certification