Basic Information
| Provider Information | |||||||||
| NPI: | 1326038381 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANGROVE MEDICAL GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MANGROVE LAB & XRAY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 MANGROVE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959263509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303450064 | ||||||||
| FaxNumber: | 5303450680 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MANGROVE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959263509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303450064 | ||||||||
| FaxNumber: | 5303450680 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2005 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/16/2021 | ||||||||
| NPIReactivationDate: | 01/04/2022 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MULLINS | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5303450064 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207VG0400X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 208D00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 261QR0206X | RHC 110619 | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology, Mammography | 291U00000X | 05DO644223 | CA | N | Laboratories | Clinical Medical Laboratory | 363L00000X | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 470000743 | 01 | CA | RAILROAD MEDICARE | OTHER |