Basic Information
| Provider Information | |||||||||
| NPI: | 1689658668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOLDEN VALLEY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 W CHILDS AVE | ||||||||
| Address2: | |||||||||
| City: | MERCED | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953416805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093846493 | ||||||||
| FaxNumber: | 2093831296 | ||||||||
| Practice Location | |||||||||
| Address1: | 637 MERCED ST | ||||||||
| Address2: | |||||||||
| City: | NEWMAN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953601070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098620270 | ||||||||
| FaxNumber: | 2098620274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 02/09/2017 | ||||||||
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| AuthorizedOfficialLastName: | WEBER | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093846493 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 040000364 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | CMM70613F | 05 | CA | MEDICAID | GR0086286 | 05 | CA | MEDICAID | 040000364 | 01 | CA | STATE OF CA LIC# | OTHER | ZZZ56431Z | 01 | CA | BLUE SHIELD OF CA GRP PIN | OTHER |