Basic Information
| Provider Information | |||||||||
| NPI: | 1083949341 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER VALLEY MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 MEDICAL PLAZA DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956613088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167815188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2009 | ||||||||
| LastUpdateDate: | 01/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 9168877398 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER MEDICAL FOUNDATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | GPT001680 | 05 | CA | MEDICAID |