Provider Demographics
NPI:1154646982
Name:ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-968-2809
Mailing Address - Street 1:1572 RAILROAD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1169
Mailing Address - Country:US
Mailing Address - Phone:707-968-2809
Mailing Address - Fax:707-963-9185
Practice Address - Street 1:15322 LAKESHORE DR
Practice Address - Street 2:SUITE 203
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-9814
Practice Address - Country:US
Practice Address - Phone:707-968-2809
Practice Address - Fax:707-963-9185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC32535207RC0000X
CAA106559208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty