1245458421 NPI number — SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT

Table of content: (NPI 1245458421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245458421 NPI number — SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
JEROLD PHELPS COMMUNITY HOSPITAL SKILLED NURSING FACILITY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245458421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
733 CEDAR ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARBERVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95542-3201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-923-3921
Provider Business Mailing Address Fax Number:
707-923-1456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
733 CEDAR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARBERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95542-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-923-3921
Provider Business Practice Location Address Fax Number:
707-923-1456
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
REES
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
E
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
707-923-3921

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  110000052 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LTC55516F . This is a "MEDI-CAL SNF" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 174988 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 272260 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3003993 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZJ1202Z . This is a "BLUE SHIELD (HOSPITAL)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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