Provider Demographics
NPI:1104194927
Name:SUTTER VALLEY MEDICAL FOUNDATION
Entity Type:Organization
Organization Name:SUTTER VALLEY MEDICAL FOUNDATION
Other - Org Name:SUTTER MEDICAL FOUNDATION PIONEER HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PHYSICIAN SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALLMARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-887-7312
Mailing Address - Street 1:2750 GATEWAY OAKS DRIVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-3658
Mailing Address - Country:US
Mailing Address - Phone:916-887-7398
Mailing Address - Fax:916-503-3886
Practice Address - Street 1:24685 HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:PIONEER
Practice Address - State:CA
Practice Address - Zip Code:95666
Practice Address - Country:US
Practice Address - Phone:209-257-7500
Practice Address - Fax:209-257-7501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUTTER MEDICAL FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-07
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR1300X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058502Medicaid
CA058502Medicaid