Provider Demographics
NPI:1053928606
Name:NOR CAL TRAUMA HEALING CENTER
Entity type:Organization
Organization Name:NOR CAL TRAUMA HEALING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:URREGO-VALLOWE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW CCSP-ADHD
Authorized Official - Phone:279-202-8113
Mailing Address - Street 1:5740 WINDMILL WAY STE 8
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1379
Mailing Address - Country:US
Mailing Address - Phone:279-202-8113
Mailing Address - Fax:
Practice Address - Street 1:5740 WINDMILL WAY STE 8
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-1379
Practice Address - Country:US
Practice Address - Phone:279-202-8113
Practice Address - Fax:916-251-1148
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA100192313Medicaid