Basic Information
| Provider Information | |||||||||
| NPI: | 1336389600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN MONTEREY COUNTY MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BROADWAY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 CANAL ST | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939303431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313867437 | ||||||||
| FaxNumber: | 8313857188 | ||||||||
| Practice Location | |||||||||
| Address1: | 809 BROADWAY ST | ||||||||
| Address2: | STE. D | ||||||||
| City: | KING CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939303303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313867437 | ||||||||
| FaxNumber: | 8313857188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2009 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALAMACHA | ||||||||
| AuthorizedOfficialFirstName: | RENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8313857284 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHERN MONTEREY COUNTY MEMORIAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | CA | N | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.