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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  N193200000X MULTI-SPECIALTY GROUPOther Service ProvidersCase Manager/Care Coordinator 
261QF0400X230000189CAY Ambulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)

ID Information
IDTypeStateIssuerDescription
125535035105CA MEDICAID
FHC70478F05CA MEDICAID
HAP70478F01CAFAMILY PLANNINGOTHER
BCP70478F01CAEWC:CDP:BCEDPOTHER


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