Provider Demographics
NPI:1346410255
Name:M A C T HEALTH BOARD, INCORPORATED
Entity Type:Organization
Organization Name:M A C T HEALTH BOARD, INCORPORATED
Other - Org Name:MACT MEDICAL SAN ANDREAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-754-6262
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:209-754-6274
Practice Address - Street 1:1113 HWY 49
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9583
Practice Address - Country:US
Practice Address - Phone:209-755-1400
Practice Address - Fax:209-755-1430
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACT HEALTH BOARD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-06
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000678261Q00000X
CA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA051153Medicare Oscar/Certification
CACD353AMedicare PIN