Provider Demographics
NPI:1063496396
Name:WESTERN SIERRA MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:WESTERN SIERRA MEDICAL CLINIC, INC.
Other - Org Name:WESTERN SIERRA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:FRANCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-802-2706
Mailing Address - Street 1:844 OLD TUNNEL RD
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-8524
Mailing Address - Country:US
Mailing Address - Phone:530-273-4984
Mailing Address - Fax:530-273-4573
Practice Address - Street 1:844 OLD TUNNEL RD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-8524
Practice Address - Country:US
Practice Address - Phone:530-273-4984
Practice Address - Fax:530-273-4573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43289261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ22465ZOtherMEDICARE ID TYPE-UNSPECIFIED
CAFHC70988FMedicaid
CA051002OtherMEDICARE ID TYPE-UNSPECIFIED
CA051002OtherMEDICARE ID TYPE-UNSPECIFIED