Basic Information
| Provider Information | |||||||||
| NPI: | 1316541865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL VALLEY HEALTH PLAN, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1303 EAST HERNDON AVENUE | ||||||||
| Address2: | MAIL STOP 500 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594503000 | ||||||||
| FaxNumber: | 5594505585 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 EAST HERNDON AVENUE | ||||||||
| Address2: | MAIL STOP 500 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594503000 | ||||||||
| FaxNumber: | 5594505585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2020 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | PRUSAITIS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5594503375 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINT AGNES MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302R00000X | Y | Managed Care Organizations | Health Maintenance Organization |
No ID Information.