Basic Information
| Provider Information | |||||||||
| NPI: | 1215157375 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL VALLEY INDIAN HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TACHI MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2740 HERNDON AVE | ||||||||
| Address2: | |||||||||
| City: | CLOVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936116813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592994264 | ||||||||
| FaxNumber: | 5592991421 | ||||||||
| Practice Location | |||||||||
| Address1: | 16835 ALKALI DR | ||||||||
| Address2: | SUITE M | ||||||||
| City: | LEMOORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932459463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592994264 | ||||||||
| FaxNumber: | 5592991421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOWLER | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5592992578 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 040000498 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | THP70892F | 05 | CA | MEDICAID |