1780668863 NPI number — GOLDEN VALLEY HEALTH CENTER

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 1780668863 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:
1780668863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2017
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:
95341-6805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-384-6493
Provider Business Mailing Address Fax Number:
209-383-1296

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 LAS VEGAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95358-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-476-4200
Provider Business Practice Location Address Fax Number:
209-556-5064
Provider Enumeration Date:
12/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WEBER
Authorized Official First Name:
TONY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
209-384-6493

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , with the licence number:  030000528 , 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: CMM70785F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ52522Z . This is a "BLUE SHIELD OF CA GRP PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 030000528 . This is a "STATE OF CA LIC#" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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