Basic Information
| Provider Information | |||||||||
| NPI: | 1609881499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER COAST HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SUTTER COAST HOME CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074648511 | ||||||||
| FaxNumber: | 7074648886 | ||||||||
| Practice Location | |||||||||
| Address1: | 785 E WASHINGTON BLVD STE 14&15 | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074648741 | ||||||||
| FaxNumber: | 7074643742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HANNA | ||||||||
| AuthorizedOfficialFirstName: | MITCH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7074648880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 010000265 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA07427F | 05 | CA | MEDICAID | HHA 07427F | 05 | CA | MEDICAID |