Provider Demographics
NPI:1649275264
Name:ST. THERESE MEDICAL GROUP
Entity type:Organization
Organization Name:ST. THERESE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-391-0305
Mailing Address - Street 1:7702 MEANY AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93308-5199
Mailing Address - Country:US
Mailing Address - Phone:661-391-0305
Mailing Address - Fax:661-391-0313
Practice Address - Street 1:511 W COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-1201
Practice Address - Country:US
Practice Address - Phone:661-391-0305
Practice Address - Fax:661-391-0313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42316174400000X, 174400000X
CA00A347910103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealthGroup - Multi-Specialty
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083054Medicaid
CAA42316OtherLICENSE
CAGR0083054Medicaid
CAA42316OtherLICENSE
CAA88264Medicare UPIN
CAZZZ16134ZMedicare ID - Type UnspecifiedCLINIC
CA00A347910Medicaid