Provider Demographics
NPI:1124220249
Name:ADVENTIST HEALTH MENDOCINO COAST
Entity Type:Organization
Organization Name:ADVENTIST HEALTH MENDOCINO COAST
Other - Org Name:MENDOCINO COAST DISTRICT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDSON
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-456-3010
Mailing Address - Street 1:PO BOX 841941
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-1941
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 RIVER DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437
Practice Address - Country:US
Practice Address - Phone:707-961-4631
Practice Address - Fax:707-964-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058629Medicare Oscar/Certification