Basic Information
| Provider Information | |||||||||
| NPI: | 1124070552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEQUOIA COMMUNITY HEALTH FOUNDATION, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1945 N FINE AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575283 | ||||||||
| FaxNumber: | 5594575892 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 FRESNO ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937063600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575700 | ||||||||
| FaxNumber: | 5594575790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | MAFFEO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5594877806 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 040000549 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC70996F | 05 | CA | MEDICAID |