Provider Demographics
| NPI: | 1003863622 |
|---|---|
| Name: | PEACH TREE HEALTHCARE |
| Entity Type: | Organization |
| Organization Name: | PEACH TREE HEALTHCARE |
| Other - Org Name: | PEACH TREE CLINIC |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | CEO |
| Authorized Official - Prefix: | MR |
| Authorized Official - First Name: | GREG |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | STONE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 530-741-6245 |
| Mailing Address - Street 1: | 1114 YUBA ST STE 220 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | MARYSVILLE |
| Mailing Address - State: | CA |
| Mailing Address - Zip Code: | 95901-4838 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 530-749-3242 |
| Mailing Address - Fax: | 530-749-3248 |
| Practice Address - Street 1: | 5730 PACKARD AVE |
| Practice Address - Street 2: | SUITE 500 |
| Practice Address - City: | MARYSVILLE |
| Practice Address - State: | CA |
| Practice Address - Zip Code: | 95901-7118 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 530-749-3242 |
| Practice Address - Fax: | 530-749-3238 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-05-28 |
| Last Update Date: | 2022-05-23 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| CA | PSY10876 | 103T00000X |
| CA | LCS12778 | 1041C0700X |
| CA | 14503TLG | 152W00000X |
| CA | A66235 | 171100000X |
| 171M00000X | ||
| CA | A368140 | 207QS0010X |
| CA | A93985 | 207V00000X |
| CA | A104819 | 207W00000X |
| CA | A60310 | 208000000X |
| CA | G42749 | 2084P0800X |
| CA | 2OA5572 | 208D00000X |
| CA | E1137 | 213E00000X |
| CA | 550000005 | 261QF0400X |
| CA | PA14393 | 363A00000X |
| CA | 18608 | 363L00000X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | Group - Multi-Specialty |
| No | 103T00000X | Behavioral Health & Social Service Providers | Psychologist | Group - Multi-Specialty | |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Multi-Specialty | |
| No | 171100000X | Other Service Providers | Acupuncturist | Group - Multi-Specialty | |
| No | 171M00000X | Other Service Providers | Case Manager/Care Coordinator | Group - Multi-Specialty | |
| No | 207QS0010X | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | Group - Multi-Specialty |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 207W00000X | Allopathic & Osteopathic Physicians | Ophthalmology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 208D00000X | Allopathic & Osteopathic Physicians | General Practice | Group - Multi-Specialty | |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CA | FHC11619G | Medicaid | |
| CA | FHC11619G | Medicaid |
