Basic Information
Provider Information | |||||||||
NPI: | 1912310855 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COUNTY OF MONTEREY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MONTEREY COUNTY INTEGRATED HEALTH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1441 SCHILLING PLACE | ||||||||
Address2: | SOUTH BLDG FLOOR 1 | ||||||||
City: | SALINAS | ||||||||
State: | CA | ||||||||
PostalCode: | 939014527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8317961308 | ||||||||
FaxNumber: | 8317570291 | ||||||||
Practice Location | |||||||||
Address1: | 299 12TH ST | ||||||||
Address2: |   | ||||||||
City: | MARINA | ||||||||
State: | CA | ||||||||
PostalCode: | 939336003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8318998168 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2014 | ||||||||
LastUpdateDate: | 06/16/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EDGCOMB | ||||||||
AuthorizedOfficialFirstName: | JULIA | ||||||||
AuthorizedOfficialMiddleName: | CLAIRE | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR/COO CLINIC SERVICES DIV. | ||||||||
AuthorizedOfficialTelephone: | 8317961386 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MONTEREY COUNTY HEALTH DEPARTMENT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.