Provider Demographics
NPI:1477586808
Name:AMPLA HEALTH
Entity Type:Organization
Organization Name:AMPLA HEALTH
Other - Org Name:AMPLA HEALTH COLUSA MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT, CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:H
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:530-751-3778
Mailing Address - Street 1:PO BOX AD
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95992-1396
Mailing Address - Country:US
Mailing Address - Phone:530-751-3778
Mailing Address - Fax:530-751-1237
Practice Address - Street 1:555 FREMONT ST
Practice Address - Street 2:
Practice Address - City:COLUSA
Practice Address - State:CA
Practice Address - Zip Code:95932-2534
Practice Address - Country:US
Practice Address - Phone:530-458-8635
Practice Address - Fax:530-458-7830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 261Q00000X
CA230000216261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70544FOtherFAMILY PLANNING
CA6865328Medicaid
CABCP70544FOtherEWC:CDP:BCEDP
ZZZ15241ZMedicare PIN
CAHAP70544FOtherFAMILY PLANNING