Basic Information
Provider Information | |||||||||
NPI: | 1780668863 | ||||||||
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: | 737 W CHILDS AVE | ||||||||
Address2: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 953416805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093846493 | ||||||||
FaxNumber: | 2093831296 | ||||||||
Practice Location | |||||||||
Address1: | 1717 LAS VEGAS ST | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953585500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2094764200 | ||||||||
FaxNumber: | 2095565064 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/02/2005 | ||||||||
LastUpdateDate: | 02/09/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WEBER | ||||||||
AuthorizedOfficialFirstName: | TONY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2093846493 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 030000528 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | CMM70785F | 05 | CA |   | MEDICAID | ZZZ52522Z | 01 | CA | BLUE SHIELD OF CA GRP PIN | OTHER | 030000528 | 01 | CA | STATE OF CA LIC# | OTHER |