Basic Information
| Provider Information | |||||||||
| NPI: | 1457854192 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KERN VALLEY HEALTHCARE DISTRICT | ||||||||
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| OtherOrganizationName: | KERN VALLEY HEALTHCARE DISTRICT RHC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6412 LAUREL AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE ISABELLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932409529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603792681 | ||||||||
| FaxNumber: | 7603794795 | ||||||||
| Practice Location | |||||||||
| Address1: | 4300 BIRCH STREET | ||||||||
| Address2: | |||||||||
| City: | MT MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603791791 | ||||||||
| FaxNumber: | 7603791793 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | FIGUEROA | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7603792681 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KERN VALLEY HEALTHCARE DISTRICT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 120000183 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHM08561F | 05 | CA | MEDICAID |