Provider Demographics
NPI:1770705139
Name:COUTY OF MENDOCINO
Entity type:Organization
Organization Name:COUTY OF MENDOCINO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:PINIZOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:707-472-2300
Mailing Address - Street 1:1120 S DORA ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-3919
Mailing Address - Country:US
Mailing Address - Phone:707-472-2300
Mailing Address - Fax:
Practice Address - Street 1:1011 LOW GAP ROAD
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-463-6878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUTY OF MENDOCINO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00023Medicaid
CA2390Medicaid