1821170044 NPI number — SOUTH COUNTY COMMUNITY HEALTH CENTER INC

Table of content: (NPI 1821170044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821170044 NPI number — SOUTH COUNTY COMMUNITY HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH COUNTY COMMUNITY HEALTH CENTER INC
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:
RAVENSWOOD FAMILY HEALTH NETWORK
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:
1821170044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1885 BAY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST PALO ALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94303-1611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-330-7400
Provider Business Mailing Address Fax Number:
650-321-1560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1885 BAY ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST PALO ALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94303-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-330-7400
Provider Business Practice Location Address Fax Number:
650-321-1560
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JACQUES
Authorized Official First Name:
GRALYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
650-330-7400

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , 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: BCP70935F . This is a "CANCER DETECTION PROGRAM" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: HAP70935F . This is a "FAMILY PACT" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: EAP70935F . This is a "EAPC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: FHC70935F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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