Basic Information
Provider Information | |||||||||
NPI: | 1174693493 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHERN TRINITY HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7 | ||||||||
Address2: |   | ||||||||
City: | SCOTIA | ||||||||
State: | CA | ||||||||
PostalCode: | 955650007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7077645617 | ||||||||
FaxNumber: | 7077835618 | ||||||||
Practice Location | |||||||||
Address1: | 321 VAN DUZEN ROAD | ||||||||
Address2: |   | ||||||||
City: | MAD RIVER | ||||||||
State: | CA | ||||||||
PostalCode: | 955520004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7075746616 | ||||||||
FaxNumber: | 7075746523 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2006 | ||||||||
LastUpdateDate: | 08/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUPTON | ||||||||
AuthorizedOfficialFirstName: | GRAYLAN | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7075746616 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2300000060 | CA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QF0400X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | 230000060 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | FHC70040F | 05 | CA |   | MEDICAID | RHM70040F | 05 | CA |   | MEDICAID |