Provider Demographics
NPI:1770639668
Name:MISSION PROVIDER SERVICES, INC.
Entity Type:Organization
Organization Name:MISSION PROVIDER SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:EMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-222-5633
Mailing Address - Street 1:2970 INNSBRUCK DR STE C
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-9303
Mailing Address - Country:US
Mailing Address - Phone:530-222-5633
Mailing Address - Fax:530-222-5528
Practice Address - Street 1:1974 CIRRUS ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-3330
Practice Address - Country:US
Practice Address - Phone:530-224-1061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000332315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55G415OtherDHS ID NUMBER