Basic Information
| Provider Information | |||||||||
| NPI: | 1821149816 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN MONO HEALTH CARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BRIDGEPORT FAMILY MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660 | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935460660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | 7609244023 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 TWIN LAKES ROAD | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609327011 | ||||||||
| FaxNumber: | 7609327180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 03/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN WINKLE | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFI | ||||||||
| AuthorizedOfficialTelephone: | 7609343311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NR1301X | 240000008 | CA | Y | Hospitals | General Acute Care Hospital | Rural |
No ID Information.