Basic Information
Provider Information | |||||||||
NPI: | 1467427310 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COPPERTOWER FAMILY MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ALEXANDER VALLEY HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 WEST THIRD ST | ||||||||
Address2: |   | ||||||||
City: | CLOVERDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 954253204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078944229 | ||||||||
FaxNumber: | 7078942954 | ||||||||
Practice Location | |||||||||
Address1: | 6 TARMAN DRIVE | ||||||||
Address2: |   | ||||||||
City: | CLOVERDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 954253932 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7078944229 | ||||||||
FaxNumber: | 7078942954 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2006 | ||||||||
LastUpdateDate: | 02/11/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAUNDERS | ||||||||
AuthorizedOfficialFirstName: | JENINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7078944229 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | HAP53824F | 01 | CA | FAMILY FACT | OTHER | RHM53824G | 05 | CA |   | MEDICAID | ZZZ47432Z | 01 | CA | MEDICARE PTAN NUMBER | OTHER |