Basic Information
| Provider Information | |||||||||
| NPI: | 1477586808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMPLA HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | AMPLA HEALTH COLUSA MEDICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 935 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959914217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307513769 | ||||||||
| FaxNumber: | 5307511237 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 FREMONT ST | ||||||||
| Address2: | |||||||||
| City: | COLUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959322534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304588635 | ||||||||
| FaxNumber: | 5304587830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
| 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: | 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 | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QF0400X | 230000216 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | HAP70544F | 01 | CA | FAMILY PLANNING | OTHER | 6865328 | 05 | CA | MEDICAID | BCP70544F | 01 | CA | EWC:CDP:BCEDP | OTHER |