Basic Information
Provider Information | |||||||||
NPI: | 1457593980 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUTTER VALLEY MEDICAL FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUTTER NORTH SURGERY CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 255228 | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958655228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9168546975 | ||||||||
FaxNumber: | 9168546844 | ||||||||
Practice Location | |||||||||
Address1: | 460 PLUMAS BLVD | ||||||||
Address2: | SUITE 202 | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 959915005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5307495500 | ||||||||
FaxNumber: | 5307495520 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/30/2009 | ||||||||
LastUpdateDate: | 11/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KREVANS | ||||||||
AuthorizedOfficialFirstName: | SARAH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9162866732 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SUTTER MEDICAL FOUNDATION | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0919786 | CA | N |   | Laboratories | Clinical Medical Laboratory |   | 291U00000X | 05D1041437 | CA | N |   | Laboratories | Clinical Medical Laboratory |   | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | SUR01359F | 05 | CA |   | MEDICAID | SUR01734F | 05 | CA |   | MEDICAID |