Provider Demographics
NPI:1114111309
Name:COMMUNITY MEMORIAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HEALTH SYSTEM
Other - Org Name:CMH CENTERS FOR FAMILY HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-652-5011
Mailing Address - Street 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:120 N ASHWOOD AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1810
Practice Address - Country:US
Practice Address - Phone:805-667-2801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-30
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT40394FMedicaid
CA=========OtherTAX IDENTIFICATION NUMBER