Provider Demographics
NPI:1982140521
Name:UPAC TRC
Entity Type:Organization
Organization Name:UPAC TRC
Other - Org Name:CRAWFORD HIGH SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUNNYO
Authorized Official - Middle Name:
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-521-5720
Mailing Address - Street 1:3288 EL CAJON BLVD STE 13
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1430
Mailing Address - Country:US
Mailing Address - Phone:619-521-5720
Mailing Address - Fax:
Practice Address - Street 1:4191 COLTS WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-6023
Practice Address - Country:US
Practice Address - Phone:619-521-5720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNION OF PAN ASIAN COMMUNITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-06
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8583Medicaid