Basic Information
| Provider Information | |||||||||
| NPI: | 1467436048 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLDEN VALLEY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953406805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093831848 | ||||||||
| FaxNumber: | 2093831296 | ||||||||
| Practice Location | |||||||||
| Address1: | 1510 FLORIDA AVE | ||||||||
| Address2: | SUITE F | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953504437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095497090 | ||||||||
| FaxNumber: | 2095497099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | ROEHLK | ||||||||
| AuthorizedOfficialFirstName: | HELEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2093855434 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 030000554 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 030000554 | 01 | CA | STATE OF CA LIC# | OTHER | ZZZ52118Z | 01 | CA | BLUE SHIELD OF CA GRP PIN | OTHER | CMM70634F | 05 | CA | MEDICAID | FHC70634F | 01 | CA | FQHC# | OTHER | GR008628A | 05 | CA | MEDICAID |