Basic Information
Provider Information | |||||||||
NPI: | 1922090489 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FEATHER RIVER TRIBAL HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2145 5TH AVE | ||||||||
Address2: |   | ||||||||
City: | OROVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 959655870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5305343793 | ||||||||
FaxNumber: | 5305343820 | ||||||||
Practice Location | |||||||||
Address1: | 555 W ONSTOTT RD | ||||||||
Address2: |   | ||||||||
City: | YUBA CITY | ||||||||
State: | CA | ||||||||
PostalCode: | 95993 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5307518454 | ||||||||
FaxNumber: | 5307518456 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/19/2005 | ||||||||
LastUpdateDate: | 08/03/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNZEKER | ||||||||
AuthorizedOfficialFirstName: | MARIA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5305343793 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 2300000265 | CA | N |   | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | BCP70683F | 01 | CA | BREAST CANCER PROGRAM | OTHER | THP70683F | 05 | CA |   | MEDICAID |