Basic Information
| Provider Information | |||||||||
| NPI: | 1780673376 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SONORA COMMUNITY HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVENTIST HEALTH SONORA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 888852 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900888852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095363900 | ||||||||
| FaxNumber: | 2095362774 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 GREENLEY RD | ||||||||
| Address2: | |||||||||
| City: | SONORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953705200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095365000 | ||||||||
| FaxNumber: | 2095362774 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 02/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCCULLOCH | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | FO | ||||||||
| AuthorizedOfficialTelephone: | 2095365011 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SONORA COMMUNITY HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 030000094 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP40335F | 05 | CA | MEDICAID | ZZR00335F | 05 | CA | MEDICAID | ZZZC5502Z | 01 | CA | BLUE CROSS/BLUE SHIELD | OTHER |