Basic Information
Provider Information | |||||||||
NPI: | 1609897529 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BI-VALLEY MEDICAL CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750576425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 1437933002 | ||||||||
FaxNumber: | 2148539018 | ||||||||
Practice Location | |||||||||
Address1: | 2100 CAPITOL AVE | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958165721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9164424985 | ||||||||
FaxNumber: | 9164421029 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2006 | ||||||||
LastUpdateDate: | 01/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
AuthorizedOfficialFirstName: | GENCO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2143793300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 34-03 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
ID | Type | State | Issuer | Description | GR0004550 | 01 | CA | MEDI-CAL | OTHER | PB0173269 | 01 | CA | DEA | OTHER | CMM70096F | 01 | CA | MEDI-CAL | OTHER |