Basic Information
| Provider Information | |||||||||
| NPI: | 1992142277 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST SIDE HEALTH CARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | WEST SIDE FAMILY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 119 ADKISSON WAY | ||||||||
| Address2: | |||||||||
| City: | TAFT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932683602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617657234 | ||||||||
| FaxNumber: | 6617454835 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | TAFT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932683606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617651935 | ||||||||
| FaxNumber: | 6617651928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 05/12/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHULTZ | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6617657234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.