Basic Information
| Provider Information | |||||||||
| NPI: | 1235310384 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VALLEYS HEALTH CENTERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 277 | ||||||||
| Address2: | |||||||||
| City: | BIEBER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960090277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302945241 | ||||||||
| FaxNumber: | 5302945392 | ||||||||
| Practice Location | |||||||||
| Address1: | 554-850 MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | BIEBER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 96009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302945241 | ||||||||
| FaxNumber: | 5302945392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 11/11/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/08/2018 | ||||||||
| NPIReactivationDate: | 05/16/2018 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5302496857 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | EAP03915F | 05 | CA | MEDICAID |