1306311329 NPI number — MARK TWAIN HEALTH CARE DISTRICT

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 1306311329 NPI number — MARK TWAIN HEALTH CARE DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK TWAIN 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:
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:
1306311329
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANDREAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95249-0095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-754-4468
Provider Business Mailing Address Fax Number:
209-754-2537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 WELLNESS WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALLEY SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95252-0051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-772-7070
Provider Business Practice Location Address Fax Number:
209-772-1011
Provider Enumeration Date:
10/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
SMART
Authorized Official First Name:
RANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
209-728-7711

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)





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