Basic Information
Provider Information | |||||||||
NPI: | 1174764021 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF VENTURA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MOORPARK FAMILY MEDICAL CLINIC FQHC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 S VICTORIA AVE # L4615 | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930090003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056775210 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 612 SPRING RD | ||||||||
Address2: |   | ||||||||
City: | MOORPARK | ||||||||
State: | CA | ||||||||
PostalCode: | 930211298 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8055235400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/23/2009 | ||||||||
LastUpdateDate: | 09/05/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOLEY | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8056775272 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | VENTURA COUNTY MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | H80CS00247-06-03 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.