Provider Demographics
NPI: | 1669654091 |
---|---|
Name: | COMMUNITY CARE |
Entity Type: | Organization |
Organization Name: | COMMUNITY CARE |
Other - Org Name: | CCHAP |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | EXECUTIVE DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CYNTHIA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MCMATH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 707-462-3041 |
Mailing Address - Street 1: | 14644B LAKESHORE DR |
Mailing Address - Street 2: | |
Mailing Address - City: | CLEARLAKE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95422-9290 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-995-1606 |
Mailing Address - Fax: | 707-995-0309 |
Practice Address - Street 1: | 14644B LAKESHORE DR |
Practice Address - Street 2: | |
Practice Address - City: | CLEARLAKE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95422-9290 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-995-1606 |
Practice Address - Fax: | 707-995-0309 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-11-27 |
Last Update Date: | 2007-11-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 302R00000X | Managed Care Organizations | Health Maintenance Organization |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 7975326 | Medicaid |