Provider Demographics
NPI:1568786408
Name:ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Other - Org Name:COON JOINT REPLACEMENT INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:A
Authorized Official - Last Name:DONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-968-2809
Mailing Address - Street 1:1572 RAILROAD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1169
Mailing Address - Country:US
Mailing Address - Phone:707-968-2809
Mailing Address - Fax:707-963-9185
Practice Address - Street 1:6 WOODLAND RD
Practice Address - Street 2:SUITE 202
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9501
Practice Address - Country:US
Practice Address - Phone:707-968-0670
Practice Address - Fax:707-968-9580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86235207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty