Basic Information
| Provider Information | |||||||||
| NPI: | 1427110329 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON COMMUNITY HEALTH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 B ST BLDG B | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953349593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947913 | ||||||||
| FaxNumber: | 2093943660 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 B ST BLDG B | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953349593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947913 | ||||||||
| FaxNumber: | 2093943660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 04/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCGOWAN | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | TAMIKO | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093941365 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | 04/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | ZZZ71885Y | 01 | CA | BLUE SHIELD | OTHER | FHC03897F | 05 | CA | MEDICAID | BCP03897F | 01 | CA | BREAST CANCER EARLY DETEC | OTHER | HAP03897F | 01 | CA | HEALTH ACCESS PROGRAM | OTHER |