Provider Demographics
NPI:1326038381
Name:MANGROVE MEDICAL GROUP
Entity Type:Organization
Organization Name:MANGROVE MEDICAL GROUP
Other - Org Name:MANGROVE LAB & XRAY
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:MULLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-345-0064
Mailing Address - Street 1:1040 MANGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3509
Mailing Address - Country:US
Mailing Address - Phone:530-345-0064
Mailing Address - Fax:530-345-0680
Practice Address - Street 1:1040 MANGROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3509
Practice Address - Country:US
Practice Address - Phone:530-345-0064
Practice Address - Fax:530-345-0680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2022-01-04
Deactivation Date:2021-12-16
Deactivation Code:
Reactivation Date:2022-01-04
Provider Licenses
StateLicense IDTaxonomies
207N00000X, 207ND0900X, 207VG0400X
CA207Q00000X, 208D00000X, 363L00000X
CARHC 110619261QR0206X
CA05DO644223291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, MammographyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA470000743OtherRAILROAD MEDICARE
CA470000743OtherRAILROAD MEDICARE
CAGR0067390Medicaid
CA1962422238Medicaid
CAZZZ15808ZMedicare PIN
CAZZZ58848ZMedicare PIN