Provider Demographics
NPI:1073981783
Name:EL DORADO COUNTY COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:EL DORADO COUNTY COMMUNITY HEALTH CENTER
Other - Org Name:EL DORADO COMMUNITY HEALTH CENTER CAMERON PARK MAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:530-748-2327
Mailing Address - Street 1:4212 MISSOURI FLAT RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6269
Mailing Address - Country:US
Mailing Address - Phone:530-621-7700
Mailing Address - Fax:530-621-7713
Practice Address - Street 1:3100 PONTE MORINO DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-7432
Practice Address - Country:US
Practice Address - Phone:530-621-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EL DORADO COUNTY COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-11
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA75-1859Medicare UPIN