Basic Information
| Provider Information | |||||||||
| NPI: | 1508192220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | JEROLD PHELPS COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 733 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | GARBERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955423201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079233921 | ||||||||
| FaxNumber: | 7079231456 | ||||||||
| Practice Location | |||||||||
| Address1: | 733 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | GARBERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955423201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7079233921 | ||||||||
| FaxNumber: | 7079231456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2009 | ||||||||
| LastUpdateDate: | 02/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SCOWN | ||||||||
| AuthorizedOfficialFirstName: | KENT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7079233921 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 110000052 | CA | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 3003993 | 05 | WA | MEDICAID | LTC30482G | 01 | CA | MEDI-CAL | OTHER | 174988 | 05 | AZ | MEDICAID | 272260 | 05 | OR | MEDICAID |