Provider Demographics
NPI:1285044990
Name:EL DORADO COUNTY COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:EL DORADO COUNTY COMMUNITY HEALTH CENTER
Other - Org Name:EL DORADO COMMUNITY HEALTH CENTER CAMERON PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-748-2327
Mailing Address - Street 1:4212 MISSOURI FLAT RD
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-6269
Mailing Address - Country:US
Mailing Address - Phone:530-621-7700
Mailing Address - Fax:530-621-7713
Practice Address - Street 1:3104 PONTE MORINO DR
Practice Address - Street 2:SUITE 110
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8282
Practice Address - Country:US
Practice Address - Phone:530-621-7700
Practice Address - Fax:530-621-7713
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EL DORADO COUNTY COMMUNITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-02
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA75-1166Medicare PIN