Basic Information
Provider Information | |||||||||
NPI: | 1629301775 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUTTER WEST BAY HOSPITALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SUTTER LAKESIDE COMMUNITY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 742412 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900742412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4156007120 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 750 OLD LUCERNE ROAD | ||||||||
Address2: |   | ||||||||
City: | UPPER LAKE | ||||||||
State: | CA | ||||||||
PostalCode: | 954850000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7072759066 | ||||||||
FaxNumber: | 7072759070 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2009 | ||||||||
LastUpdateDate: | 01/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNTER | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: | TRENT | ||||||||
AuthorizedOfficialTitleorPosition: | VP SHARED SERVICES | ||||||||
AuthorizedOfficialTelephone: | 9162978555 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 110000094 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | RKY18547F | 05 | CA |   | MEDICAID |