Provider Demographics
NPI:1730130097
Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:CANYON SPRINGS COMMUNITY FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-2822
Mailing Address - Street 1:1215 O STREET
Mailing Address - Street 2:CFS: MS 10-30
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95814
Mailing Address - Country:US
Mailing Address - Phone:916-654-3463
Mailing Address - Fax:916-653-4587
Practice Address - Street 1:69696 RAMON RD
Practice Address - Street 2:
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3353
Practice Address - Country:US
Practice Address - Phone:760-770-6200
Practice Address - Fax:760-328-2769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170000774313M00000X, 315P00000X, 320900000X, 333600000X
315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU661Medicare PIN