Provider Demographics
NPI:1215578885
Name:GRASSROOTS HEALTHCARE FOUNDATION
Entity Type:Organization
Organization Name:GRASSROOTS HEALTHCARE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-992-5809
Mailing Address - Street 1:732 PLACER CIR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-7882
Mailing Address - Country:US
Mailing Address - Phone:707-992-5809
Mailing Address - Fax:707-210-0480
Practice Address - Street 1:732 PLACER CIR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-7882
Practice Address - Country:US
Practice Address - Phone:707-992-5809
Practice Address - Fax:707-210-0480
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRASSROOTS HEALTHCARE FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-03
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)