Provider Demographics
NPI:1831478148
Name:COUNTY OF MENDOCINO
Entity Type:Organization
Organization Name:COUNTY OF MENDOCINO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-472-2621
Mailing Address - Street 1:790 S FRANKLIN ST
Mailing Address - Street 2:SUITE #B
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5456
Mailing Address - Country:US
Mailing Address - Phone:707-472-2621
Mailing Address - Fax:
Practice Address - Street 1:790 S FRANKLIN ST
Practice Address - Street 2:SUITE #B
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5456
Practice Address - Country:US
Practice Address - Phone:707-472-2621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF MENDOCINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2302OtherMEDI-CAL #