Basic Information
| Provider Information | |||||||||
| NPI: | 1336367515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERN HUMBOLDT COMMUNITY HOSPITAL DISTRICT | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 733 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | GARBERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955423201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079233921 | ||||||||
| FaxNumber: | 7079231456 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 ELM ST | ||||||||
| Address2: | |||||||||
| City: | GARBERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955423204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079233921 | ||||||||
| FaxNumber: | 7079231456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 07/01/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARDNER | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | MED STAFF COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7079233921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 110000052 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 174988 | 05 | AZ | MEDICAID | 272260 | 05 | OR | MEDICAID | RHM03921G | 01 | CA | MEDI-CAL | OTHER | 3003993 | 05 | WA | MEDICAID | ZZZ05354Z | 01 | CA | BLUE SHIELD CLINIC | OTHER |