Provider Demographics
NPI:1225089592
Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:FAIRVIEW DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-2822
Mailing Address - Street 1:1215 O STREET
Mailing Address - Street 2:CFS: MS 10-30
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814
Mailing Address - Country:US
Mailing Address - Phone:916-654-3463
Mailing Address - Fax:916-653-4587
Practice Address - Street 1:2501 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-6143
Practice Address - Country:US
Practice Address - Phone:714-957-5000
Practice Address - Fax:714-957-5095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170000771282E00000X, 282N00000X, 314000000X, 315P00000X, 333600000X
CAHPE97703336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No282E00000XHospitalsLong Term Care Hospital
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU661AMedicare PIN
CA050548Medicare Oscar/Certification