Provider Demographics
NPI:1164886040
Name:PEACH TREE HEALTHCARE
Entity Type:Organization
Organization Name:PEACH TREE HEALTHCARE
Other - Org Name:PEACH TREE NORTH SACRAMENTO
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:S
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-741-6245
Mailing Address - Street 1:1114 YUBA ST STE 220
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-4838
Mailing Address - Country:US
Mailing Address - Phone:530-749-3242
Mailing Address - Fax:530-749-3248
Practice Address - Street 1:3810 ROSIN CT
Practice Address - Street 2:SUITE 100
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95834-1656
Practice Address - Country:US
Practice Address - Phone:530-741-6245
Practice Address - Fax:530-741-9274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA030000463261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA751916OtherPTAN