Provider Demographics
NPI:1083600894
Name:POTTER VALLEY COMMUNITY HEALTH CTR
Entity Type:Organization
Organization Name:POTTER VALLEY COMMUNITY HEALTH CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EX DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:N
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-743-1188
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:POTTER VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95469-0238
Mailing Address - Country:US
Mailing Address - Phone:707-743-1188
Mailing Address - Fax:707-743-1192
Practice Address - Street 1:10175 MAIN ST
Practice Address - Street 2:
Practice Address - City:POTTER VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95469-9749
Practice Address - Country:US
Practice Address - Phone:707-743-1188
Practice Address - Fax:707-743-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFHC03879F261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03879FMedicaid
CAFHC03879FMedicaid
A41322Medicare UPIN
051920Medicare ID - Type Unspecified