Provider Demographics
NPI:1174653059
Name:CHAPA-DE INDIAN HEALTH PROGRAM, INC.
Entity Type:Organization
Organization Name:CHAPA-DE INDIAN HEALTH PROGRAM, INC.
Other - Org Name:WOODLAND CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:SIERK
Authorized Official - Middle Name:
Authorized Official - Last Name:HAITSMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-887-2841
Mailing Address - Street 1:11670 ATWOOD RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-9522
Mailing Address - Country:US
Mailing Address - Phone:530-887-2800
Mailing Address - Fax:530-887-2807
Practice Address - Street 1:175 W COURT ST
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2913
Practice Address - Country:US
Practice Address - Phone:530-887-2800
Practice Address - Fax:530-887-2807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000513261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP70647FMedicaid
CA051925Medicare Oscar/Certification