1407068059 NPI number — MARJORIE SHELTON-GROSS

Table of content: MARJORIE SHELTON-GROSS (NPI 1407068059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407068059 NPI number — MARJORIE SHELTON-GROSS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHELTON-GROSS
Provider First Name:
MARJORIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1407068059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1442 ETHAN WAY
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-2231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-481-8600
Provider Business Mailing Address Fax Number:
916-481-9636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1469 HUMBOLDT RD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95928-9116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-891-1917
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VH0002X , with the licence number:  G455730 , 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: CMM70268F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMM70370F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CMM70116G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZR11629F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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