Basic Information
| Provider Information | |||||||||
| NPI: | 1326031881 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREENVILLE RANCHERIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GREENVILLE RANCHERIA TRIBAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 279 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959470279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302847990 | ||||||||
| FaxNumber: | 5302847299 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959470279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302846135 | ||||||||
| FaxNumber: | 5302847594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 03/12/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 08/21/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | FISCAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5302847990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | THP70390G | 05 | CA | MEDICAID |