Provider Demographics
NPI:1457485617
Name:TUOLUMNE COUNTY CCS - SOULSBYVILLE MTU
Entity Type:Organization
Organization Name:TUOLUMNE COUNTY CCS - SOULSBYVILLE MTU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PUBLIC HEALTH NURSING
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:AMOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-533-7403
Mailing Address - Street 1:2 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20300 SOULSBYVILLE RD
Practice Address - Street 2:
Practice Address - City:SOULSBYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95372-9738
Practice Address - Country:US
Practice Address - Phone:209-532-5198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACCS00120FMedicaid