Basic Information
| Provider Information | |||||||||
| NPI: | 1992736599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOCTORS HOSPITAL OF MANTECA, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DOCTORS HOSPITAL OF MANTECA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 57435 | ||||||||
| Address2: | FILE 57435 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900747435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095782513 | ||||||||
| FaxNumber: | 2092398329 | ||||||||
| Practice Location | |||||||||
| Address1: | 1205 E NORTH ST | ||||||||
| Address2: | |||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953364932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2098233111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARRISON | ||||||||
| AuthorizedOfficialFirstName: | GREGG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2098238362 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 030000203 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | ZZZC3910Z | 01 | BS OF CALIFORNIA | OTHER | HSC00118G | 05 | CA | MEDICAID | 163607300 | 01 | AETNA US HEALTHCARE (NATI | OTHER | 005073-0001 | 01 | PACIFICARE OF CALIFORNIA | OTHER | ZZR00118G | 05 | CA | MEDICAID | 000413 | 01 | HUMANA | OTHER | HSP40118G | 05 | CA | MEDICAID | HSC30118G | 05 | CA | MEDICAID | HSP40118H | 05 | CA | MEDICAID |