Basic Information
| Provider Information | |||||||||
| NPI: | 1770688129 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUTTER VALLEY MEDICAL FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 255228 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958655228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1625 STOCKTON BLVD STE 208 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444212250 | ||||||||
| FaxNumber: | 9168877867 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 12/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | MOLLOY | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF QUALITY MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 9167317857 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CLF334507 | CA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | LAB56694F | 05 | CA | MEDICAID |