Provider Demographics
NPI:1295858074
Name:COUNTY OF MERCED
Entity Type:Organization
Organization Name:COUNTY OF MERCED
Other - Org Name:BHRS YOUTH OUTPATIENT- LOS BANOS
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:CIPP/US
Authorized Official - Phone:209-381-6818
Mailing Address - Street 1:P.O. BOX 2087
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95344-0087
Mailing Address - Country:US
Mailing Address - Phone:209-381-6800
Mailing Address - Fax:
Practice Address - Street 1:40 W G ST STE A-E
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3657
Practice Address - Country:US
Practice Address - Phone:209-710-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2453Medicaid