Basic Information
| Provider Information | |||||||||
| NPI: | 1316121007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN TRINITY HEALTH INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7 | ||||||||
| Address2: | |||||||||
| City: | SCOTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955650007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077645617 | ||||||||
| FaxNumber: | 7077835618 | ||||||||
| Practice Location | |||||||||
| Address1: | 153-A VAN DUZEN RD | ||||||||
| Address2: | |||||||||
| City: | MAD RIVER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075746616 | ||||||||
| FaxNumber: | 7075746523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2007 | ||||||||
| LastUpdateDate: | 04/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LUPTON | ||||||||
| AuthorizedOfficialFirstName: | GRAYLAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7075746616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | EAP70040F | 05 | CA | MEDICAID |