Basic Information
Provider Information | |||||||||
NPI: | 1710087515 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNICARE HEALTH CENTERS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SALUD CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1260 | ||||||||
Address2: |   | ||||||||
City: | DAVIS | ||||||||
State: | CA | ||||||||
PostalCode: | 956171260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5307533498 | ||||||||
FaxNumber: | 5307582109 | ||||||||
Practice Location | |||||||||
Address1: | 500 B JEFFERSON BLVD | ||||||||
Address2: | #180 | ||||||||
City: | WEST SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 95605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9163756400 | ||||||||
FaxNumber: | 9163756413 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STANLEY | ||||||||
AuthorizedOfficialFirstName: | KRISTIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF INFORMATION OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5307533498 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | FHC70983F | 05 | CA |   | MEDICAID | ZZZ26460Z | 05 | CA |   | MEDICAID |