Basic Information
| Provider Information | |||||||||
| NPI: | 1265697841 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUOIA COMMUNITY HEALTH FOUNDATION, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SEQUOIA COMMUNITY HEALTH CENTERS GARLAND | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1945 N FINE AVENUE | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937271528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3727 N 1ST ST | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937265628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594576900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2008 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAFFEO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5594575800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 550000725 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CDP PROGRAM | 05 | CA | MEDICAID |