Provider Demographics
NPI:1467427310
Name:COPPERTOWER FAMILY MEDICAL CENTER
Entity Type:Organization
Organization Name:COPPERTOWER FAMILY MEDICAL CENTER
Other - Org Name:ALEXANDER VALLEY HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-894-4229
Mailing Address - Street 1:106 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CLOVERDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95425-3746
Mailing Address - Country:US
Mailing Address - Phone:707-669-1780
Mailing Address - Fax:707-894-2954
Practice Address - Street 1:6 TARMAN DRIVE
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:CA
Practice Address - Zip Code:95425-3932
Practice Address - Country:US
Practice Address - Phone:707-894-4229
Practice Address - Fax:707-894-2954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53824GMedicaid
CAHAP53824FOtherFAMILY FACT
CAZZZ47432ZOtherMEDICARE PTAN NUMBER
CARHM53824GMedicaid