Basic Information
| Provider Information | |||||||||
| NPI: | 1033534466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COPPERTOWER FAMILY MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALEXANDER VALLEY HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078944229 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 TARMAN DR | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078944229 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2014 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | SAUNDERS | ||||||||
| AuthorizedOfficialFirstName: | JENINE | ||||||||
| AuthorizedOfficialMiddleName: | ROSE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7078944229 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 110000318 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.