Provider Demographics
NPI:1629301775
Name:SUTTER WEST BAY HOSPITALS
Entity Type:Organization
Organization Name:SUTTER WEST BAY HOSPITALS
Other - Org Name:SUTTER LAKESIDE COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP SHARED SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-297-8555
Mailing Address - Street 1:PO BOX 742412
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-2412
Mailing Address - Country:US
Mailing Address - Phone:415-600-7120
Mailing Address - Fax:
Practice Address - Street 1:750 OLD LUCERNE ROAD
Practice Address - Street 2:
Practice Address - City:UPPER LAKE
Practice Address - State:CA
Practice Address - Zip Code:95485-0000
Practice Address - Country:US
Practice Address - Phone:707-275-9066
Practice Address - Fax:707-275-9070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000094261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARKY18547FMedicaid
CARKY18547FMedicaid