Provider Demographics
NPI:1760465637
Name:MATHER VA
Entity Type:Organization
Organization Name:MATHER VA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:NOREEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOODIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:916-366-5450
Mailing Address - Street 1:8607 OLIVEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-6317
Mailing Address - Country:US
Mailing Address - Phone:917-967-7176
Mailing Address - Fax:
Practice Address - Street 1:8607 OLIVEWOOD CT
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-6317
Practice Address - Country:US
Practice Address - Phone:917-967-7176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14656261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care