Provider Demographics
NPI:1710423793
Name:SHINGLE SPRINGS RANCHERIA
Entity Type:Organization
Organization Name:SHINGLE SPRINGS RANCHERIA
Other - Org Name:SHINGLE SPRINGS HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY/PIC/AO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BODTKER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:530-387-8005
Mailing Address - Street 1:5168 HONPIE RD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-8682
Mailing Address - Country:US
Mailing Address - Phone:530-387-8005
Mailing Address - Fax:530-387-8006
Practice Address - Street 1:5168 HONPIE RD
Practice Address - Street 2:5TH FLOOR
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-8682
Practice Address - Country:US
Practice Address - Phone:530-387-8215
Practice Address - Fax:530-676-4416
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-13
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY55274332800000X
333600000X, 3336C0002X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710423793Medicaid
2167303OtherPK