1831522333 NPI number — MENDOCINO COAST HOSPITALITY CENTER

Table of content: (NPI 1831522333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831522333 NPI number — MENDOCINO COAST HOSPITALITY CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MENDOCINO COAST HOSPITALITY 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:
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:
1831522333
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2168
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT BRAGG
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-961-0172
Provider Business Mailing Address Fax Number:
707-961-0217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N FRANKLIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BRAGG
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-961-0172
Provider Business Practice Location Address Fax Number:
844-388-6167
Provider Enumeration Date:
08/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
707-941-0408

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 23CR , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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