Basic Information
| Provider Information | |||||||||
| NPI: | 1245301308 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VALLEYS HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BURNEY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37491 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | BURNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960134380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303355457 | ||||||||
| FaxNumber: | 5303353388 | ||||||||
| Practice Location | |||||||||
| Address1: | 37491 ENTERPRISE DR | ||||||||
| Address2: | |||||||||
| City: | BURNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960134380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303355457 | ||||||||
| FaxNumber: | 5303353388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2006 | ||||||||
| LastUpdateDate: | 04/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | THORLAKSSON | ||||||||
| AuthorizedOfficialFirstName: | SHERAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5302945112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MOUNTAIN VALLEY HEALTH CENTERS INC. | ||||||||
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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 | 1245301308 | 05 | CA | MEDICAID |