Basic Information
| Provider Information | |||||||||
| NPI: | 1205851151 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMPLA HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AMPLA HEALTH LA PALOMA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX AD | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959921396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307513769 | ||||||||
| FaxNumber: | 5307511237 | ||||||||
| Practice Location | |||||||||
| Address1: | 1574 KIRK RD | ||||||||
| Address2: | |||||||||
| City: | GRIDLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959489417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308463707 | ||||||||
| FaxNumber: | 5308463709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 01/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FLORES | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5307513739 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MPH | ||||||||
| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 5537638 | 05 | CA | MEDICAID |