Basic Information
| Provider Information | |||||||||
| NPI: | 1306853296 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER COAST HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUTTER COAST HEALTH CLINIC @ BROOKINGS-HARBOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074648511 | ||||||||
| FaxNumber: | 7074648886 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 5TH ST | ||||||||
| Address2: | |||||||||
| City: | BROOKINGS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974159730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414699205 | ||||||||
| FaxNumber: | 5414699204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 10/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | HANNA | ||||||||
| AuthorizedOfficialFirstName: | MITCH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7074648880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER COAST HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 840162000 | 01 | OR | BX REGENCE | OTHER | 227691 | 05 | OR | MEDICAID | CT3220 | 01 | RAILROAD RETIRE | OTHER |