Provider Demographics
NPI:1881166296
Name:PES-EBS.INC.
Entity type:Organization
Organization Name:PES-EBS.INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:STOCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-888-1010
Mailing Address - Street 1:11837 KEMPER RD STE 2
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-9067
Mailing Address - Country:US
Mailing Address - Phone:530-888-1010
Mailing Address - Fax:
Practice Address - Street 1:2060 CHICAGO AVE STE A9
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2316
Practice Address - Country:US
Practice Address - Phone:530-888-1010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-24
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8048Medicaid