Provider Demographics
NPI:1184080681
Name:SACRAMENTO CHILD AND ADOLESCENT WELLNESS CENTER CORP
Entity type:Organization
Organization Name:SACRAMENTO CHILD AND ADOLESCENT WELLNESS CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-955-3149
Mailing Address - Street 1:2742 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2402
Mailing Address - Country:US
Mailing Address - Phone:916-508-4069
Mailing Address - Fax:
Practice Address - Street 1:2001 N ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-4237
Practice Address - Country:US
Practice Address - Phone:916-538-2477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA93664261QM0801X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)