1114017100 NPI number — VALLEY FAMILY HEALTH CENTER MEDICAL GROUP, INC.

Table of content: (NPI 1114017100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114017100 NPI number — VALLEY FAMILY HEALTH CENTER MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY FAMILY HEALTH CENTER MEDICAL GROUP, 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:
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:
1114017100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 543
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERDALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93656-0543
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-867-4416
Provider Business Mailing Address Fax Number:
559-867-3010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1288 N IRWIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HANFORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93230-2956
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-582-2025
Provider Business Practice Location Address Fax Number:
559-582-2520
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
559-867-4416

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: HAP53913F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: RHM53913F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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