Basic Information
| Provider Information | |||||||||
| NPI: | 1295773224 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CMH CENTERS FOR FAMILY HEALTH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5855 OLIVAS PARK DR | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672801 | ||||||||
| FaxNumber: | 8056672865 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 W MAIN ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930012584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672850 | ||||||||
| FaxNumber: | 8056520708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILDE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8056525011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY MEMORIAL HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | ZZT40394F | 05 | CA | MEDICAID |