Provider Demographics
NPI:1780721720
Name:CCS MEDICAL THERAPY PROGRAM
Entity type:Organization
Organization Name:CCS MEDICAL THERAPY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PUBLIC HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CONSTANTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-868-0301
Mailing Address - Street 1:1800 MT. VERNON AVENUE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD,
Mailing Address - State:CA
Mailing Address - Zip Code:93306-3302
Mailing Address - Country:US
Mailing Address - Phone:661-868-0306
Mailing Address - Fax:661-868-0268
Practice Address - Street 1:1959 PRINCETON ST.
Practice Address - Street 2:ROOM 33
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-1523
Practice Address - Country:US
Practice Address - Phone:661-725-6452
Practice Address - Fax:661-725-6170
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KERN COUNTY DEPARTMENT OF PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00112FMedicaid