Basic Information
Provider Information | |||||||||
NPI: | 1679764070 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SEQUOIA COMMUNITY HEALTH FOUNDATION INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SEQUOIA COMMUNITY HEALTH CENTERS - DIV/WHC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1945 NORTH FINE AVE | ||||||||
Address2: | SUITE 116 | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937271528 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5594575835 | ||||||||
FaxNumber: | 5594575892 | ||||||||
Practice Location | |||||||||
Address1: | 145 NORTH CLARK | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937012108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5594575919 | ||||||||
FaxNumber: | 5594575993 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2007 | ||||||||
LastUpdateDate: | 08/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WAIYAKI | ||||||||
AuthorizedOfficialFirstName: | SYBILLE | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5594575837 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | HAP71152F | 01 | CA | DIV/WHC FPACT | OTHER |