Basic Information
| Provider Information | |||||||||
| NPI: | 1902106198 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLE HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY HEALTH CLINIC OLE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1141 PEAR TREE LN STE 100 | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945586485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541770 | ||||||||
| FaxNumber: | 7072541779 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HARTLE CT. | ||||||||
| Address2: | |||||||||
| City: | NAPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945594078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072541774 | ||||||||
| FaxNumber: | 7072512988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2010 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | ALICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7072541774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC11719F | 05 | CA | MEDICAID |