1831522333 NPI number — MENDOCINO COAST HOSPITALITY CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831522333 NPI number — MENDOCINO COAST HOSPITALITY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDOCINO COAST HOSPITALITY CENTER
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:
Provider Other Organization Name Type Code:
6
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:
1831522333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-961-0172
Provider Business Mailing Address Fax Number:
707-961-0217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N FRANKLIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-961-0172
Provider Business Practice Location Address Fax Number:
844-388-6167
Provider Enumeration Date:
08/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
707-941-0408

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 23CR , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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