Provider Demographics
NPI:1093085565
Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:LANTERMAN COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTCHINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-1897
Mailing Address - Street 1:1600 9TH ST STE 205
Mailing Address - Street 2:MS 2-3
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814-6435
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-653-4587
Practice Address - Street 1:3530 W POMONA BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91768-3238
Practice Address - Country:US
Practice Address - Phone:909-444-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU661Medicare PIN
CA05-0545Medicare PIN