Provider Demographics
NPI:1821455395
Name:IMPERIAL COUNTY BEHAVIORAL HEALTH SERVICES
Entity Type:Organization
Organization Name:IMPERIAL COUNTY BEHAVIORAL HEALTH SERVICES
Other - Org Name:BRAWLEY CHILDREN AND ADOLESCENTS OUTPATIENT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:442-265-1605
Mailing Address - Street 1:195 S. 9TH ST.
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-9762
Mailing Address - Country:US
Mailing Address - Phone:442-265-5080
Mailing Address - Fax:760-351-7701
Practice Address - Street 1:195 S. 9TH ST.
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-9762
Practice Address - Country:US
Practice Address - Phone:442-265-5080
Practice Address - Fax:760-351-7701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMPERIAL COUNTY BEHAVIORAL HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
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