Basic Information
| Provider Information | |||||||||
| NPI: | 1356595409 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANCER DETECTION PROGRAM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAMMOTH HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100 | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935460100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | 7609244023 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SIERRA PARK ROAD | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | 7609244023 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2008 | ||||||||
| LastUpdateDate: | 11/14/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOYD | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7609343311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | N | Hospitals | General Acute Care Hospital | Critical Access | 282NR1301X | Y | Hospitals | General Acute Care Hospital | Rural |
ID Information
| ID | Type | State | Issuer | Description | RHM18523F | 01 | CA | RURAL HEALTH IDENTIFICATION NUMBER | OTHER |