Provider Demographics
NPI:1376821108
Name:EDGAR ONTIVEROS
Entity Type:Organization
Organization Name:EDGAR ONTIVEROS
Other - Org Name:MENTAL HEALTH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CASE MANAGER HISPANIC OUTREACH
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:RINCON
Authorized Official - Last Name:ONTIVEROS
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:1707-263-4338
Mailing Address - Street 1:15204 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-8107
Mailing Address - Country:US
Mailing Address - Phone:170-726-3433
Mailing Address - Fax:170-726-3433
Practice Address - Street 1:15204 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8107
Practice Address - Country:US
Practice Address - Phone:170-726-3433
Practice Address - Fax:170-726-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-27
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management