Basic Information
| Provider Information | |||||||||
| NPI: | 1356829576 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN SIERRA MEDICAL CLINIC, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN SIERRA MEDICAL CLINIC - PENN VALLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 844 OLD TUNNEL RD | ||||||||
| Address2: | |||||||||
| City: | GRASS VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959458524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302734984 | ||||||||
| FaxNumber: | 5302734573 | ||||||||
| Practice Location | |||||||||
| Address1: | 10544 SPENCEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | PENN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959469623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302734984 | ||||||||
| FaxNumber: | 5302734573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | NOVAK | ||||||||
| AuthorizedOfficialFirstName: | FRANCINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF PLANNING AND DEVELOPMEN OFFIC | ||||||||
| AuthorizedOfficialTelephone: | 5302734984 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN SIERRA MEDICAL CLINIC, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 230000145 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 1851513469 | 05 | CA | MEDICAID |