Basic Information
| Provider Information | |||||||||
| NPI: | 1275941676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENDOCINO COUNTY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COUNTY OF MENDOCINO HEALTH & HUMAN SERVICES PUBLIC HEALTH BRANCH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 S DORA ST | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954826340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074722730 | ||||||||
| FaxNumber: | 7074722735 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 S DORA ST | ||||||||
| Address2: | |||||||||
| City: | UKIAH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954826340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074722730 | ||||||||
| FaxNumber: | 7074722735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2014 | ||||||||
| LastUpdateDate: | 07/29/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CONVERY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR OF NURSING | ||||||||
| AuthorizedOfficialTelephone: | 7074722707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | 36SC1501X | CA | Y | Agencies | Public Health or Welfare |
No ID Information.