Basic Information
Provider Information | |||||||||
NPI: | 1144770793 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN SIERRA MEDICAL CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WESTERN SIERRA MEDICAL CLINIC - LOCKSLEY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 844 OLD TUNNEL RD | ||||||||
Address2: |   | ||||||||
City: | GRASS VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 959458524 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302749762 | ||||||||
FaxNumber: | 5302734573 | ||||||||
Practice Location | |||||||||
Address1: | 12183 LOCKSLEY LN STE 107 | ||||||||
Address2: |   | ||||||||
City: | AUBURN | ||||||||
State: | CA | ||||||||
PostalCode: | 95602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302734984 | ||||||||
FaxNumber: | 5302734573 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2016 | ||||||||
LastUpdateDate: | 07/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NOVAK | ||||||||
AuthorizedOfficialFirstName: | FRANCINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF PLANNING AND DEVELOPMENT OFFI | ||||||||
AuthorizedOfficialTelephone: | 5302734984 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WESTERN SIERRA MEDICAL CLINIC, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 230000145 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1851513469 | 01 | CA | PARENT NPI | OTHER |