Basic Information
| Provider Information | |||||||||
| NPI: | 1629059746 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER CENTRAL VALLEY HOSPITALS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 740152 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900740152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553981633 | ||||||||
| FaxNumber: | 2095727772 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095264500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | GATES | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO SHBA | ||||||||
| AuthorizedOfficialTelephone: | 5104507357 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0609849 | CA | N | Laboratories | Clinical Medical Laboratory | 282N00000X | 030000061 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | MTA00603F | 05 | CA | MEDICAID | ZZR00154F | 05 | CA | MEDICAID | HSC00557F | 05 | CA | MEDICAID | HSP40557F | 05 | CA | MEDICAID | ZZR00603F | 05 | CA | MEDICAID |