Provider Demographics
NPI:1780803239
Name:COUNTY OF SISKIYOU
Entity type:Organization
Organization Name:COUNTY OF SISKIYOU
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE SERVICES MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-841-4732
Mailing Address - Street 1:2060 CAMPUS DR
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-9538
Mailing Address - Country:US
Mailing Address - Phone:530-841-4100
Mailing Address - Fax:530-841-4230
Practice Address - Street 1:2060 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9538
Practice Address - Country:US
Practice Address - Phone:530-841-4100
Practice Address - Fax:530-841-4230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01114108Medicaid