1679503759 NPI number — CHW MEDICAL FOUNDATION

Table of content: (NPI 1679503759)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679503759 NPI number — CHW MEDICAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHW MEDICAL FOUNDATION
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:
1679503759
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3000 Q ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-7058
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-733-5701
Provider Business Mailing Address Fax Number:
916-733-3401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6620 COYLE AVE
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
CARMICHAEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95608-6333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-961-6946
Provider Business Practice Location Address Fax Number:
916-961-7217
Provider Enumeration Date:
07/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HYLEN
Authorized Official First Name:
THERESA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
916-851-2559

Provider Taxonomy Codes

  • Taxonomy code: 261QR0206X , with the licence number:  18528 , 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: GR0011372 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ17567Z . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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