Basic Information
| Provider Information | |||||||||
| NPI: | 1114059474 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNICARE HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KNIGHTS LANDING COMMUNITY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1260 | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956171260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307533498 | ||||||||
| FaxNumber: | 5307582109 | ||||||||
| Practice Location | |||||||||
| Address1: | 9586 MILL STREET | ||||||||
| Address2: | |||||||||
| City: | KNIGHT LANDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307351776 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STANLEY | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL INFO SYSTEMS | ||||||||
| AuthorizedOfficialTelephone: | 5307533498 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC11771F | 05 | CA | MEDICAID |