Basic Information
| Provider Information | |||||||||
| NPI: | 1922179498 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN VALLEYS HEALTH CENTERS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FALL RIVER VALLEY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER MILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960280490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303366535 | ||||||||
| FaxNumber: | 5303355166 | ||||||||
| Practice Location | |||||||||
| Address1: | 43658 STATE HIGHWAY 299 E | ||||||||
| Address2: | |||||||||
| City: | FALL RIVER MILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960289787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303366535 | ||||||||
| FaxNumber: | 5303355166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/17/2019 | ||||||||
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| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5302945241 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1922179498 | 05 | CA | MEDICAID |