Provider Demographics
NPI:1558366823
Name:OLE HEALTH
Entity Type:Organization
Organization Name:OLE HEALTH
Other - Org Name:DAVIS COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACISAAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-767-6435
Mailing Address - Street 1:PO BOX 1260
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95617
Mailing Address - Country:US
Mailing Address - Phone:530-753-3498
Mailing Address - Fax:530-758-2109
Practice Address - Street 1:2051 JOHN JONES RD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-9701
Practice Address - Country:US
Practice Address - Phone:530-758-2060
Practice Address - Fax:530-758-8490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA03000146261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11771FMedicaid
CA051003Medicare Oscar/Certification