Provider Demographics
NPI:1649468968
Name:COUNTY OF MENDOCINO
Entity type:Organization
Organization Name:COUNTY OF MENDOCINO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BHRS DEPUTY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:707-472-2637
Mailing Address - Street 1:1120 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-6340
Mailing Address - Country:US
Mailing Address - Phone:707-472-2637
Mailing Address - Fax:707-472-2657
Practice Address - Street 1:518 LOW GAP RD
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-3735
Practice Address - Country:US
Practice Address - Phone:707-472-2637
Practice Address - Fax:707-472-2657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare
No261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal
No261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2305Medicaid
CA2305OtherDRUG MEDI-CAL