Provider Demographics
NPI:1326098161
Name:DEPARTMENT OF STATE HOSPITALS
Entity Type:Organization
Organization Name:DEPARTMENT OF STATE HOSPITALS
Other - Org Name:DEPARTMENT OF STATE HOSPITALS - NAPA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATIVE DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-651-3238
Mailing Address - Street 1:1215 O STREET, MS-3
Mailing Address - Street 2:DEPARTMENT OF STATE HOSPITALS - PCRS
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814
Mailing Address - Country:US
Mailing Address - Phone:916-651-8906
Mailing Address - Fax:916-651-8908
Practice Address - Street 1:2100 NAPA VALLEJO HWY
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6234
Practice Address - Country:US
Practice Address - Phone:707-253-5000
Practice Address - Fax:707-253-5513
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF STATE HOSPITALS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150000492282N00000X, 310500000X, 314000000X, 333600000X, 3336L0003X
283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA054122Medicare Oscar/Certification
CAAR738Medicare PIN