Basic Information
| Provider Information | |||||||||
| NPI: | 1336174564 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH HOSPITAL EUREKA WILLOW CREEK FAMILY HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WILLOW CREEK FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 726 | ||||||||
| Address2: | 38883 HWY 299 | ||||||||
| City: | WILLOW CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955730726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306293111 | ||||||||
| FaxNumber: | 5306293122 | ||||||||
| Practice Location | |||||||||
| Address1: | 38883 HWY 299 | ||||||||
| Address2: | |||||||||
| City: | WILLOW CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955730726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306293111 | ||||||||
| FaxNumber: | 5306293122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 01/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEN OUDEN | ||||||||
| AuthorizedOfficialFirstName: | ROSEMARY | ||||||||
| AuthorizedOfficialMiddleName: | FRANCES | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5306293111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHM03886G | 05 | CA | MEDICAID | BCP03886G | 05 | CA | MEDICAID |