Basic Information
Provider Information
NPI: 1699907436
EntityType: 2
ReplacementNPI:  
OrganizationName: OUTPATIENT AND SPECIALTY CENTER AT SIERRA KINGS DISTRICT HOSPITAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: SIERRA KINGS HEALTH CARE DISTRICT
OtherOrganizationType: 5
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 372 W. CYPRESS AVE
Address2:  
City: REEDLEY
State: CA
PostalCode: 936542113
CountryCode: US
TelephoneNumber: 5596388155
FaxNumber: 5596387555
Practice Location
Address1: 372 W CYPRESS AVE
Address2:  
City: REEDLEY
State: CA
PostalCode: 936542113
CountryCode: US
TelephoneNumber: 5596388155
FaxNumber: 5596387555
Other Information
ProviderEnumerationDate: 08/12/2009
LastUpdateDate: 08/12/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: OTT
AuthorizedOfficialFirstName: PAMELA
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CHIEF EXECUTIVE OFFICER
AuthorizedOfficialTelephone: 5596388155
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR1300XAPPLIED FOR/PENDINGCAY Ambulatory Health Care FacilitiesClinic/CenterRural Health

ID Information
IDTypeStateIssuerDescription
APPLIED FOR/PENDING05CA MEDICAID
APPLIED FOR/PENDING01 MEDICARE, TYPE UNSPECIFIEDOTHER


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