Basic Information
| Provider Information | |||||||||
| NPI: | 1174858435 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUTTER VALLEY MEDICAL FOUNDATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUTTER MEDICAL FOUNDATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1340 LAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956165673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307535338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2009 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | BRIDGET | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9168877398 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUTTER VALLEY 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 | GPT001681 | 05 | CA | MEDICAID |