1720166705 NPI number — SIERRA NEVADA MEMORIAL-MINERS HOSPITAL

Table of content: (NPI 1720166705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720166705 NPI number — SIERRA NEVADA MEMORIAL-MINERS HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIERRA NEVADA MEMORIAL-MINERS HOSPITAL
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:
1720166705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
155 GLASSON WAY
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:
95945-5723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-274-6000
Provider Business Mailing Address Fax Number:
530-274-6234

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 CATHERINE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-5719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-274-6175
Provider Business Practice Location Address Fax Number:
530-274-6234
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CANADY
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
530-274-6099

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  230000152 , 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: CGP127135 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZR00150F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0051930 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZC2905Z . This is a "BLUE SHIELD OF CA" identifier . This identifiers is of the category "OTHER".
  • Identifier: HSP40150F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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