Provider Demographics
NPI:1780668863
Name:GOLDEN VALLEY HEALTH CENTER
Entity Type:Organization
Organization Name:GOLDEN VALLEY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-384-6493
Mailing Address - Street 1:737 W CHILDS AVE
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6805
Mailing Address - Country:US
Mailing Address - Phone:209-384-6493
Mailing Address - Fax:209-383-1296
Practice Address - Street 1:1717 LAS VEGAS ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-5500
Practice Address - Country:US
Practice Address - Phone:209-476-4200
Practice Address - Fax:209-556-5064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000528261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70785FMedicaid
CAZZZ52522ZOtherBLUE SHIELD OF CA GRP PIN
CA030000528OtherSTATE OF CA LIC#
CAZZZ13263ZMedicare PIN
CAZZZ52522ZOtherBLUE SHIELD OF CA GRP PIN