1346565173 NPI number — ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.

Table of content: (NPI 1346565173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346565173 NPI number — ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVENTIST HEALTH CALIFORNIA 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:
1346565173
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1572 RAILROAD AVE
Provider Second Line Business Mailing Address:
SUITE 2
Provider Business Mailing Address City Name:
SAINT HELENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94574-1169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-968-2809
Provider Business Mailing Address Fax Number:
707-963-9185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15322 LAKESHORE DR
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CLEARLAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95422-9814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-994-2920
Provider Business Practice Location Address Fax Number:
707-994-2917
Provider Enumeration Date:
04/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DONNELLY
Authorized Official First Name:
KAYE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
707-968-2809

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  G45994 , 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)





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