Basic Information
| Provider Information | |||||||||
| NPI: | 1013195221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON COMMUNITY HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LIVINGSTON MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953341257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947075 | ||||||||
| FaxNumber: | 2093943660 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953341257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947075 | ||||||||
| FaxNumber: | 2093943660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2008 | ||||||||
| LastUpdateDate: | 02/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | AURORA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093947075 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | EAP03897F | 01 | CA | EXPANDED ACCESS FOR PRIMA | OTHER |