NPIMap

Organization Active NPI

Department of State Hospitals

Doing business as Department of State Hospitals - Patton

  • Psychiatric Hospital
  • Patton, CA
National Provider Identifier
1043249204
Registry record updated Jun 28, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric HospitalTaxonomy code 283Q00000X
License
170000831 Issued in CA
Legal business name
DEPARTMENT OF STATE HOSPITALS
Doing business as
Department of State Hospitals - Patton
Practice address
3102 E Highland Ave
Patton, CA 92369-7813
Phone
(909) 425-7552
Fax
(909) 425-6407
NPI assigned
Jul 1, 2006
Last updated
Jun 28, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
DEPARTMENT OF STATE HOSPITALSAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 28, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Guadalupe M Alonzo-Diaz
Title
Administrative Deputy Director
Phone
(916) 654-2655

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
General Acute Care Hospital 282N00000X 170000831 CA
Psychiatric Hospital 283Q00000X 170000831 CA Primary
Mental Illness Intermediate Care Facility 310500000X 170000831 CA
Pharmacy 333600000X 170000831 CA
Forensic Psychologist 103TF0200X 170000831 CA
Long Term Care Pharmacy 3336L0003X 170000831 CA

Addresses

Primary practice location

3102 E Highland Ave
Patton, CA 92369-7813

Mailing address

1215 O Street, Ms-3
Patient Cost Recovery Section
Sacramento, CA 95814-6414
Phone (916) 651-8811

Other names 1

  • Department of State Hospitals - Patton Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20081031000305 CA Part B Supplier - Clinic/Group Practice 9638174238 Receives reassigned benefits from 751 practitioners
4 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Atascadero, CA; Coalinga, CA; Napa, CA; Norwalk, CA; Patton, CA
O20090129000379 CA Part A Provider - Hospital 9638174238 Practice locations: Patton, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1043249204. Details of each certification follow.

Hospital certification: CCN 05124E

Legal name
DEPARTMENT OF STATE HOSPITALS
Doing business as
PATTON STATE HOSPITAL
Organization structure
OtherNon-profit
Enrollment address
3102 E Highland Ave
Patton, CA 92369-7813
Other Hospital Practice Location
Hospital subgroups
Psychiatric

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 4

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
05D0914394Department of State Hospitals - Patton3102 East Highland Ave Eb BLDG, 2ND FL, Patton, CA 92369Provider-performed microscopyApr 28, 2028

National Provider Directory

National Provider Directory
Tax ID family
Dept of State Hospitals5 organizations share this tax ID, including this one
Part of
Dept of State Hospitals

Other organizations with this tax ID 4

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1600 9th St
Ste 150
Sacramento, CA 95814
Phone (916) 651-8811

Ownership & related parties

All disclosed owners & managing parties 6

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Wendy Ly Individual W-2 Managing EmployeeStaff Services Manager L Oct 22, 2018
Glenn Fujii Individual W-2 Managing Employee Dec 16, 1970
Stephanie L Clendenin Individual Corporate DirectorChief Deputy Director Jan 7, 2015
Sean Hammer Individual Corporate DirectorDeputy Director Mar 18, 2022
Samantha Auduong Individual W-2 Managing EmployeeDelegated Official Mar 8, 2022
Department of State Hospitals Organization, Patton, CA Operational/Managerial Control Oct 1, 1982

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Napa State HospitalNapa, CA, CCN 054122 Hospital Operational/Managerial Control Jul 1, 2011
Metropolitan State HospitalNorwalk, CA, CCN 054133 Hospital Operational/Managerial Control (100%) Jul 1, 2011
Atascadero State HospitalAtascadero, CA, CCN 05125E Hospital Operational/Managerial Control Oct 1, 1982

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 3

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 157

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 157

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151712000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1624838400000",
    "number": "1043249204",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1215 O STREET, MS-3",
            "address_2": "PATIENT COST RECOVERY SECTION",
            "city": "SACRAMENTO",
            "state": "CA",
            "postal_code": "958146414",
            "telephone_number": "916-651-8811",
            "fax_number": "916-651-8908"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3102 E HIGHLAND AVE",
            "city": "PATTON",
            "state": "CA",
            "postal_code": "923697813",
            "telephone_number": "909-425-7552",
            "fax_number": "909-425-6407"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEPARTMENT OF STATE HOSPITALS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DEPARTMENT OF STATE HOSPITALS",
        "enumeration_date": "2006-07-01",
        "last_updated": "2021-06-28",
        "certification_date": "2021-06-07",
        "status": "A",
        "authorized_official_last_name": "ALONZO-DIAZ",
        "authorized_official_first_name": "GUADALUPE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "ADMINISTRATIVE DEPUTY DIRECTOR",
        "authorized_official_telephone_number": "916-654-2655"
    },
    "taxonomies": [
        {
            "code": "282N00000X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital",
            "state": "CA",
            "license": "170000831",
            "primary": false
        },
        {
            "code": "283Q00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Hospital",
            "state": "CA",
            "license": "170000831",
            "primary": true
        },
        {
            "code": "310500000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Mental Illness",
            "state": "CA",
            "license": "170000831",
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "CA",
            "license": "170000831",
            "primary": false
        },
        {
            "code": "103TF0200X",
            "taxonomy_group": "",
            "desc": "Psychologist, Forensic",
            "state": "CA",
            "license": "170000831",
            "primary": false
        },
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": "CA",
            "license": "170000831",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Department of State Hospitals - Patton",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Department of State Hospitals - Patton",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Patton, CA

Sources for this page

Verify at the official NPI Registry.