Provider Demographics
NPI:1114923919
Name:EASTERN PLUMAS HEALTH CARE DISTRICT
Entity Type:Organization
Organization Name:EASTERN PLUMAS HEALTH CARE DISTRICT
Other - Org Name:EASTERN PLUMAS HEALTH CARE PORTOLA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JERILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:530-832-6578
Mailing Address - Street 1:500 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-9406
Mailing Address - Country:US
Mailing Address - Phone:530-832-6600
Mailing Address - Fax:
Practice Address - Street 1:480 1ST AVE
Practice Address - Street 2:
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-9405
Practice Address - Country:US
Practice Address - Phone:530-832-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA058522261QR1300X
CA230000014261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM18522FMedicaid
CAZZZ30855ZOtherBLUE SHILED CLINIC PRO FE
CAZZZ30855ZOtherBLUE SHILED CLINIC PRO FE
CA=========OtherTAX ID NUMBER