Basic Information
| Provider Information | |||||||||
| NPI: | 1417505918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACT HEALTH BOARD, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | |||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952220939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 52 S MAIN STREET, SUITE B | ||||||||
| Address2: | |||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546262 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2019 | ||||||||
| LastUpdateDate: | 08/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | ALEXANDER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | SHAWVER | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2097546258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MACT HEALTH BOARD, INCORPORATED | ||||||||
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| AuthorizedOfficialCredential: | EXECUTIVE DIRECTOR | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 1366519431 | 01 | CA | FQHC | OTHER |