Provider Demographics
NPI:1407076011
Name:IMPERIAL COUNTY BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:IMPERIAL COUNTY BEHAVIORAL HEALTH SERVICES
Other - Org Name:YOUTH AND YOUNG ADULT SERVICES - FIRST FLOOR MENVIELLE BUILDING
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:442-265-1602
Mailing Address - Street 1:202 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-2302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1295 STATE ST
Practice Address - Street 2:101,102,103,106
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2845
Practice Address - Country:US
Practice Address - Phone:442-265-1525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL COUNTY BEHAVIORAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-26
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1228Medicare PIN