1477586808 NPI number — AMPLA HEALTH

Table of content: (NPI 1477586808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477586808 NPI number — AMPLA HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMPLA HEALTH
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:
AMPLA HEALTH COLUSA MEDICAL
Provider Other Organization Name Type Code:
5
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:
1477586808
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX AD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YUBA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95992-1396
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-751-3778
Provider Business Mailing Address Fax Number:
530-751-1237

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 FREMONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95932-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-458-8635
Provider Business Practice Location Address Fax Number:
530-458-7830
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLORES
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT, CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
530-751-3778

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: 230000216 , 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: HAP70544F . This is a "FAMILY PLANNING" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 6865328 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: BCP70544F . This is a "EWC:CDP:BCEDP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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