Provider Demographics
NPI:1841241130
Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:SIERRA VISTA COMMUNITY FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-1963
Mailing Address - Street 1:PO BOX 944202
Mailing Address - Street 2:1600 9TH STREET
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:94244-2020
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:1251 STABLER LN
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-2616
Practice Address - Country:US
Practice Address - Phone:530-822-7000
Practice Address - Fax:530-822-3289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA150000488313M00000X, 315P00000X, 320900000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU661Medicare PIN