Provider Demographics
NPI:1336123926
Name:GOLDEN VALLEY HEALTH CENTER
Entity Type:Organization
Organization Name:GOLDEN VALLEY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-384-6493
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-6805
Mailing Address - Country:US
Mailing Address - Phone:209-384-6493
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1510 FLORIDA AVE
Practice Address - Street 2:SUITE H
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4437
Practice Address - Country:US
Practice Address - Phone:209-574-1030
Practice Address - Fax:209-574-1038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000554261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70634FOtherFQHC#
CAZZZ52118ZOtherBLUE SHIELD OF CA GRP PIN
CAGR008628AMedicaid
CACMM70634FOtherCMM#
CA030000554OtherSTATE OF CA LIC#
CAGR008628AMedicaid
CAGR008628AMedicaid