Provider Demographics
NPI:1548304660
Name:COUNTY OF SANTA CRUZ
Entity type:Organization
Organization Name:COUNTY OF SANTA CRUZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-454-4000
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4663
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SANTA CRUZ
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4416Medicaid
CA1659315430OtherSANTA CRUZ COUNTY CLINIC-CENTER LEGAL ORG NPI#
CAFHC70042FOtherSANTA CRUZ COUNTY MEDI-CAL GROUP#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#