Provider Demographics
NPI:1316572563
Name:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Entity Type:Organization
Organization Name:ST. JUDE NEIGHBORHOOD HEALTH CENTERS
Other - Org Name:ST. MARY HEALTH CENTERS - APPLE VALLEY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-899-9631
Mailing Address - Street 1:18077 OUTER HWY 18 STE 100
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18077 OUTER HWY 18 STE 100
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2168
Practice Address - Country:US
Practice Address - Phone:760-946-8169
Practice Address - Fax:760-946-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care