Basic Information
Provider Information | |||||||||
NPI: | 1588669865 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOLD COUNTRY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GOLD COUNTRY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4301 GOLDEN CENTER DR | ||||||||
Address2: |   | ||||||||
City: | PLACERVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956676260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306211100 | ||||||||
FaxNumber: | 5306211104 | ||||||||
Practice Location | |||||||||
Address1: | 4301 GOLDEN CENTER DR | ||||||||
Address2: |   | ||||||||
City: | PLACERVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 956676260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306211100 | ||||||||
FaxNumber: | 5306211104 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2005 | ||||||||
LastUpdateDate: | 10/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARTMAN | ||||||||
AuthorizedOfficialFirstName: | STUART | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | V.P. OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 5622575100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 030000229 | CA | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | LTC55180F | 05 | CA |   | MEDICAID |