Provider Demographics
NPI:1598786352
Name:WEST COUNTY HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:WEST COUNTY HEALTH CENTERS, INC.
Other - Org Name:RUSSIAN RIVER HEALTH CENTER BUILDING #2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TARI
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-869-5977
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:GUERNEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95446-1449
Mailing Address - Country:US
Mailing Address - Phone:707-869-2933
Mailing Address - Fax:707-869-2663
Practice Address - Street 1:16312 THIRD STREET
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-2933
Practice Address - Fax:707-869-2663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAXXXXXXX261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70957FMedicaid