Provider Demographics
NPI:1467450718
Name:VISITING NURSE ASSOCIATION OF THE MOTHER LODE
Entity Type:Organization
Organization Name:VISITING NURSE ASSOCIATION OF THE MOTHER LODE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FISCAL SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-533-6839
Mailing Address - Street 1:20100 CEDAR RD N
Mailing Address - Street 2:P.O. BOX 4805
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-5957
Mailing Address - Country:US
Mailing Address - Phone:209-533-6800
Mailing Address - Fax:
Practice Address - Street 1:20100 CEDAR RD N
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5957
Practice Address - Country:US
Practice Address - Phone:209-533-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR11355HMedicaid
CA057247Medicare ID - Type UnspecifiedPROVIDER ID