Basic Information
| Provider Information | |||||||||
| NPI: | 1124300207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HILMAR HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953341257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947913 | ||||||||
| FaxNumber: | 2093949093 | ||||||||
| Practice Location | |||||||||
| Address1: | 7970 LANDER AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HILMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953248310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092621819 | ||||||||
| FaxNumber: | 2092621817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2011 | ||||||||
| LastUpdateDate: | 01/07/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGOWAN | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093941365 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIVINGSTON COMMUNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.