Basic Information
| Provider Information | |||||||||
| NPI: | 1063875128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALEXANDER VALLEY HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1428 PRENTICE DR | ||||||||
| Address2: | |||||||||
| City: | HEALDSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954483009 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6 TARMAN DR | ||||||||
| Address2: | |||||||||
| City: | CLOVERDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954253932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078944229 | ||||||||
| FaxNumber: | 7078942954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | CARDIEL-TREJO | ||||||||
| AuthorizedOfficialFirstName: | ELENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7078942954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COPPERTOWER FAMILY MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 95002663 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.