Basic Information
| Provider Information | |||||||||
| NPI: | 1104941145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINICA SIERRA VISTA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LAMONT COMMUNITY HEALTH CENTER - MEDICAL GROUP HOSPITAL NPI | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1559 | ||||||||
| Address2: | |||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933021559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6616353050 | ||||||||
| FaxNumber: | 6618691503 | ||||||||
| Practice Location | |||||||||
| Address1: | 8787 HALL RD | ||||||||
| Address2: | |||||||||
| City: | LAMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932411953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618453731 | ||||||||
| FaxNumber: | 6618451157 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEAVE | ||||||||
| AuthorizedOfficialFirstName: | OLGA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6616353050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | FHC03895F | 01 | CA | FQHC | OTHER | GR# 0053190 | 01 | CA | MULTI-SPECIALTY | OTHER |