Provider Demographics
NPI:1073693651
Name:SURPRISE VALLEY HEALTH CARE DISTRICT
Entity Type:Organization
Organization Name:SURPRISE VALLEY HEALTH CARE DISTRICT
Other - Org Name:SURPRISE VALLEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-279-6111
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96104-0246
Mailing Address - Country:US
Mailing Address - Phone:530-279-6111
Mailing Address - Fax:530-279-2680
Practice Address - Street 1:745 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:CA
Practice Address - Zip Code:96104
Practice Address - Country:US
Practice Address - Phone:530-279-6111
Practice Address - Fax:530-279-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000025261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABCP13983FMedicaid
CARHM13983FMedicaid
CAHAP13983FMedicaid
CA053983Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER