Basic Information
| Provider Information | |||||||||
| NPI: | 1619236023 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN TRINITY HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WE CARE - SCOTIA BLUFFS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7 | ||||||||
| Address2: | |||||||||
| City: | SCOTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955650007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077645617 | ||||||||
| FaxNumber: | 7077833511 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | SCOTIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955650001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077645617 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2012 | ||||||||
| LastUpdateDate: | 05/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AULTMAN | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 7077645617 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | 230000060 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 551128 | 01 | CA | MEDICARE OSCAR/CERTIFICATION | OTHER | FHC70040F | 05 | CA | MEDICAID | RHM70040F | 05 | CA | MEDICAID |