Basic Information
Provider Information | |||||||||
NPI: | 1528202090 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUTTER CENTRAL VALLEY HOSPITALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEMORIAL HOSPITAL LOS BANOS/RURAL HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 740152 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900740152 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8553981633 | ||||||||
FaxNumber: | 2095697417 | ||||||||
Practice Location | |||||||||
Address1: | 400 W I ST STE C | ||||||||
Address2: |   | ||||||||
City: | LOS BANOS | ||||||||
State: | CA | ||||||||
PostalCode: | 936353459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2097106333 | ||||||||
FaxNumber: | 2098270554 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2009 | ||||||||
LastUpdateDate: | 04/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GATES | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO VPBA | ||||||||
AuthorizedOfficialTelephone: | 5104507357 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 040000177 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.