Provider Demographics
NPI:1003822453
Name:SOLEDAD COMMUNITY HEALTH CARE DISTRICT
Entity Type:Organization
Organization Name:SOLEDAD COMMUNITY HEALTH CARE DISTRICT
Other - Org Name:SOLEDAD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:IDA
Authorized Official - Middle Name:LOPEZ
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-678-2462
Mailing Address - Street 1:612 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOLEDAD
Mailing Address - State:CA
Mailing Address - Zip Code:93960-2533
Mailing Address - Country:US
Mailing Address - Phone:831-678-2462
Mailing Address - Fax:831-678-1539
Practice Address - Street 1:600 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960-2533
Practice Address - Country:US
Practice Address - Phone:831-678-2462
Practice Address - Fax:831-678-1539
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLEDAD COMMUNITY HEALTH CARE DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-31
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000327261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53997FMedicaid
CARHM53997FMedicaid