Basic Information
| Provider Information | |||||||||
| NPI: | 1043272172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAWEAH DELTA HEALTH CARE DISTRICT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | KAWEAH HEALTH EXETER CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 400 W MINERAL KING AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932916237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596242739 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1014 SAN JUAN AVE | ||||||||
| Address2: | |||||||||
| City: | EXETER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932211312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596242000 | ||||||||
| FaxNumber: | 5597132356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TUPPER | ||||||||
| AuthorizedOfficialFirstName: | MALINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SRVP/CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5596244065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KAWEAH DELTA HEALTH CARE DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251X00000X | N | Agencies | Supports Brokerage | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 261QR1300X | 120000580 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | RHM18508G | 05 | CA | MEDICAID | BCP18508G | 05 | CA | MEDICAID | ZZZ54779Z | 01 | CA | BLUE SHIELD | OTHER | HAP18508G | 05 | CA | MEDICAID |