Basic Information
| Provider Information | |||||||||
| NPI: | 1205002938 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARK TWAIN MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | FAMILY MEDICAL CENTER - SAN ANDREAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 768 MOUNTAIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952499707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097543521 | ||||||||
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| Practice Location | |||||||||
| Address1: | 704 MOUNTAIN RANCH RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANDREAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952499707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097543521 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2008 | ||||||||
| LastUpdateDate: | 05/12/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2097542614 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARK TWAIN MEDICAL CENTER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.