Basic Information
| Provider Information | |||||||||
| NPI: | 1740422286 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER VALLEY MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | SUTTER NORTH BROWNSVILLE FAMILY PRACTICE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168546975 | ||||||||
| FaxNumber: | 9168546844 | ||||||||
| Practice Location | |||||||||
| Address1: | 16911 WILLOW GLEN ROAD | ||||||||
| Address2: | |||||||||
| City: | BROWNSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306752457 | ||||||||
| FaxNumber: | 5306750530 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2009 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | KREVANS | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9162866732 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 05D0617902 | CA | N | Laboratories | Clinical Medical Laboratory | 261QR1300X | 230000331 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHM53950G | 05 | CA | MEDICAID |