Basic Information
| Provider Information | |||||||||
| NPI: | 1285215400 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MACT HEALTH BOARD INCORPORATED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MACT MEDICAL, IONE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | |||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952220939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546262 | ||||||||
| FaxNumber: | 2097546275 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 PRESTON AVE | ||||||||
| Address2: | |||||||||
| City: | IONE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956409158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546262 | ||||||||
| FaxNumber: | 2097546275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2021 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | SHAWVER | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2097546258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MACT HEALTH BOARD INCORPORATED | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.