Basic Information
| Provider Information | |||||||||
| NPI: | 1154609436 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5855 OLIVAS PARK DR | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672801 | ||||||||
| FaxNumber: | 8056672865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 MARICOPA HWY | ||||||||
| Address2: | STE A | ||||||||
| City: | OJAI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930233169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056402323 | ||||||||
| FaxNumber: | 8056402321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2011 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILDE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8056672801 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CMH CENTERS FOR FAMILY HEALTH OJAI | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
No ID Information.