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1792 Tribute Rd Suite 350 Sacramento CA 95815-4305 | |
| (916) 924-6400 | |
| (916) 648-9869 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Adolescent And Children Mental Health |
| Location | 1792 Tribute Rd, Sacramento, California |
| Authorized Official Name and Position | Theresa M Hylen (CHIEF FINANCIAL OFFICER) |
| Authorized Official Contact | 9168512559 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 60000 File #72938 San Francisco CA 94160-2938 Ph: (916) 733-3397 | 1792 Tribute Rd Suite 350 Sacramento CA 95815-4305 Ph: (916) 924-6400 |
| NPI Number | 1942334339 |
|---|---|
| Provider Enumeration Date | 03/15/2007 |
| Last Update Date | 11/18/2020 |
| Certification Date | 11/18/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942334339 | NPI | - | NPPES |
| 983 | Other | HEALTH NET | |
| 0019838 | Other | CIGNA | |
| ZZZ29342Z | Other | BSCA PRO FEES | |
| ZZZ60278Z | Other | BLUE SHIELD | |
| 476040021 | Other | DME SUPPLIER # | |
| GR006356C | Medicaid | CA | |
| 341996544 | Other | SPECIAL PURPOSE TAX ID # | |
| 195 | Other | HEALTH NET |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0855X | Clinic/center - Adolescent And Children Mental Health | (* (Not Available)) | Primary |
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