Basic Information
| Provider Information | |||||||||
| NPI: | 1245458421 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JEROLD PHELPS COMMUNITY HOSPITAL SKILLED NURSING FACILITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 733 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | GARBERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955423201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079233921 | ||||||||
| FaxNumber: | 7079231456 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | GARBERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955423201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079233921 | ||||||||
| FaxNumber: | 7079231456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 01/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REES | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7079233921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 110000052 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | LTC55516F | 01 | CA | MEDI-CAL SNF | OTHER | 174988 | 05 | AZ | MEDICAID | 272260 | 05 | OR | MEDICAID | 3003993 | 05 | WA | MEDICAID | ZZZJ1202Z | 01 | CA | BLUE SHIELD (HOSPITAL) | OTHER |