Basic Information
Provider Information | |||||||||
NPI: | 1568671832 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNITED HEALTH CENTERS OF THE SAN JOAQUIN VALLEY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 790 | ||||||||
Address2: |   | ||||||||
City: | PARLIER | ||||||||
State: | CA | ||||||||
PostalCode: | 936480790 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5596463561 | ||||||||
FaxNumber: | 5596463642 | ||||||||
Practice Location | |||||||||
Address1: | 476 E WASHINGTON | ||||||||
Address2: |   | ||||||||
City: | EARLIMART | ||||||||
State: | CA | ||||||||
PostalCode: | 93219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6618492781 | ||||||||
FaxNumber: | 6618495719 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLORES | ||||||||
AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
AuthorizedOfficialMiddleName: | H | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5596466618 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | BCP03861F | 01 | CA | CANCER DETECTION PROGRAM | OTHER |