Provider Demographics
NPI:1295819639
Name:ALPINE CREEK AND PINE VALLEY FAMILY MEDICINE INC.
Entity Type:Organization
Organization Name:ALPINE CREEK AND PINE VALLEY FAMILY MEDICINE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:619-445-0204
Mailing Address - Street 1:1347 TAVERN RD STE 9
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-3897
Mailing Address - Country:US
Mailing Address - Phone:619-445-0205
Mailing Address - Fax:619-659-0205
Practice Address - Street 1:1347 TAVERN RD STE 9
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-3897
Practice Address - Country:US
Practice Address - Phone:619-445-0205
Practice Address - Fax:619-659-0205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4384204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ48102ZOtherBLUE SHIELD
CA00AX43840Medicaid
CA00AX62390Medicaid
CAW20A4384AMedicare ID - Type UnspecifiedJAMES M RICKETTS, D.O.
CA00AX43840Medicaid
CA00AX62390Medicaid
CAZZZ48102ZOtherBLUE SHIELD