Basic Information
Provider Information | |||||||||
NPI: | 1710124524 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOLDEN VALLEY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2101 TENAYA DR | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953543930 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095766766 | ||||||||
FaxNumber: | 2095766770 | ||||||||
Practice Location | |||||||||
Address1: | 737 W CHILDS AVE | ||||||||
Address2: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 953416805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093846493 | ||||||||
FaxNumber: | 2093831296 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2009 | ||||||||
LastUpdateDate: | 02/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEBER | ||||||||
AuthorizedOfficialFirstName: | TONY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2093846493 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | GOLDEN VALLEY HEALTH CENTERS | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550000688 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.