Provider Demographics
NPI:1629284609
Name:SANTA CRUZ COUNTY CCS
Entity Type:Organization
Organization Name:SANTA CRUZ COUNTY CCS
Other - Org Name:DUNCAN HOLBERT MTU
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR PROGRAM MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DYBDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-763-8914
Mailing Address - Street 1:1080 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1966
Mailing Address - Country:US
Mailing Address - Phone:831-622-8400
Mailing Address - Fax:831-761-6167
Practice Address - Street 1:140 HERMAN AVE
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-2920
Practice Address - Country:US
Practice Address - Phone:831-688-8400
Practice Address - Fax:831-722-1114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00065FMedicaid