1306324512 NPI number — WESTERN SIERRA MEDICAL CLINIC, INC.

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 1306324512 NPI number — WESTERN SIERRA MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN SIERRA MEDICAL CLINIC, 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:
WESTERN SIERRA MEDICAL CLINIC - KINGS BEACH
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:
1306324512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
844 OLD TUNNEL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRASS VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95945-8524
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-273-4984
Provider Business Mailing Address Fax Number:
530-273-4573

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8665 SALMON AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGS BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-273-4984
Provider Business Practice Location Address Fax Number:
530-273-4573
Provider Enumeration Date:
07/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
NOVAK
Authorized Official First Name:
FRANCINE
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF PLANNING AND DEVELOPMENT OFFI
Authorized Official Telephone Number:
530-273-4984

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  230000145 , 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: 1851513469 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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