Provider Demographics
NPI:1295109817
Name:CASA PACIFICA
Entity type:Organization
Organization Name:CASA PACIFICA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:MIZELLA
Authorized Official - Middle Name:NONE
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINSTRATION
Authorized Official - Phone:805-445-7800
Mailing Address - Street 1:1722 LEWIS ROAD
Mailing Address - Street 2:49
Mailing Address - City:CAMIRRILO
Mailing Address - State:CA
Mailing Address - Zip Code:93004-2610
Mailing Address - Country:US
Mailing Address - Phone:805-445-7800
Mailing Address - Fax:805-987-0258
Practice Address - Street 1:1021 SCANDIA AVE
Practice Address - Street 2:49
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-2473
Practice Address - Country:US
Practice Address - Phone:805-248-1705
Practice Address - Fax:805-987-0258
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:5450
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29100322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children