1821149816 NPI number — SOUTHERN MONO HEALTH CARE DISTRICT

Table of content: (NPI 1821149816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821149816 NPI number — SOUTHERN MONO HEALTH CARE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MONO HEALTH CARE 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:
BRIDGEPORT FAMILY MEDICINE CLINIC
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:
1821149816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAMMOTH LAKES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93546-0660
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-934-3311
Provider Business Mailing Address Fax Number:
760-924-4023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 TWIN LAKES ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-932-7011
Provider Business Practice Location Address Fax Number:
760-932-7180
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN WINKLE
Authorized Official First Name:
MELANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFI
Authorized Official Telephone Number:
760-934-3311

Provider Taxonomy Codes

  • Taxonomy code: 282NR1301X , with the licence number:  240000008 , 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)





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