Provider Demographics
NPI:1982990206
Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Entity Type:Organization
Organization Name:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Other - Org Name:PORTERVILLE DEVELOPMENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANNERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-654-2232
Mailing Address - Street 1:PO BOX 944202
Mailing Address - Street 2:1600 9TH STREET ROOM 205
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:94244-2020
Mailing Address - Country:US
Mailing Address - Phone:916-654-2431
Mailing Address - Fax:916-654-3186
Practice Address - Street 1:26501 AVENUE 140
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-9109
Practice Address - Country:US
Practice Address - Phone:559-782-2222
Practice Address - Fax:559-782-5630
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF CALIFORNIA - DEPARTMENT OF DEVELOPMENTAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-24
Last Update Date:2011-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA170000837315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities