Basic Information
| Provider Information | |||||||||
| NPI: | 1962444059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN MONO HEALTH CARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MAMMOTH HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 660 | ||||||||
| Address2: | 85 SIERRA PARK RD. | ||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | 7609244149 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SIERRA PARK RD | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935462073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
| FaxNumber: | 7609244149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 02/25/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VAN WINKLE | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7609343311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | 240000008 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP30638H | 05 | CA | MEDICAID | HAP18523F | 05 | CA | MEDICAID | RHM18523F | 05 | CA | MEDICAID | HSP40638H | 05 | CA | MEDICAID |