Basic Information
Provider Information | |||||||||
NPI: | 1255350351 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMPLA HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AMPLA HEALTH RICHLAND MEDICAL | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX AD | ||||||||
Address2: |   | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 959921396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5307513778 | ||||||||
FaxNumber: | 5307511237 | ||||||||
Practice Location | |||||||||
Address1: | 355 SAMUEL DR | ||||||||
Address2: |   | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 959916324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5306749200 | ||||||||
FaxNumber: | 5306745667 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 10/11/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHISSIE | ||||||||
AuthorizedOfficialFirstName: | VICKI | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 5307513778 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/11/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |   | 261QF0400X | 230000189 | CA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1255350351 | 05 | CA |   | MEDICAID | FHC70478F | 05 | CA |   | MEDICAID | HAP70478F | 01 | CA | FAMILY PLANNING | OTHER | BCP70478F | 01 | CA | EWC:CDP:BCEDP | OTHER |