Basic Information
| Provider Information | |||||||||
| NPI: | 1275786063 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINICA SIERRA VISTA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WEST FRESNO COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6616353050 | ||||||||
| FaxNumber: | 6618691503 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 FRESNO ST | ||||||||
| Address2: | SUITE #101, #103, #200, #204 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937063600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594575700 | ||||||||
| FaxNumber: | 5594575790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEAVE | ||||||||
| AuthorizedOfficialFirstName: | OLGA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6616353050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 040000549 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | ZZZ54419Y | 01 | CA | BLUE SHIELD | OTHER |