Provider Demographics
NPI:1700580305
Name:AT PROVIDER GROUP OF CALIFORNIA PC
Entity Type:Organization
Organization Name:AT PROVIDER GROUP OF CALIFORNIA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MULLINGS
Authorized Official - Suffix:
Authorized Official - Credentials:LCADC III
Authorized Official - Phone:951-691-9101
Mailing Address - Street 1:3550 WATT AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-2666
Mailing Address - Country:US
Mailing Address - Phone:845-769-8758
Mailing Address - Fax:
Practice Address - Street 1:3550 WATT AVE STE 140
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-2666
Practice Address - Country:US
Practice Address - Phone:845-769-8758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility