1467436048 NPI number — GOLDEN VALLEY HEALTH CENTER

Table of content: (NPI 1467436048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467436048 NPI number — GOLDEN VALLEY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN VALLEY HEALTH 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:
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:
1467436048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
737 W CHILDS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERCED
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95340-6805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-383-1848
Provider Business Mailing Address Fax Number:
209-383-1296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 FLORIDA AVE
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95350-4437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-549-7090
Provider Business Practice Location Address Fax Number:
209-549-7099
Provider Enumeration Date:
12/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ROEHLK
Authorized Official First Name:
HELEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
209-385-5434

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  030000554 , 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: 030000554 . This is a "STATE OF CA LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ52118Z . This is a "BLUE SHIELD OF CA GRP PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CMM70634F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: FHC70634F . This is a "FQHC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR008628A , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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