Basic Information
| Provider Information | |||||||||
| NPI: | 1528433588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIVINGSTON COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BENTLEY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953341257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093947913 | ||||||||
| FaxNumber: | 2093943660 | ||||||||
| Practice Location | |||||||||
| Address1: | 12619 BENTLEY ST | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953869011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094426200 | ||||||||
| FaxNumber: | 2093949093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2015 | ||||||||
| LastUpdateDate: | 08/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGOWAN | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093947913 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIVINGSTON COMMUNITY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 751901 | 01 | CA | MEDICARE OSCAR/CERTIFICATION | OTHER |