Provider Demographics
NPI:1780673376
Name:SONORA COMMUNITY HOSPITAL
Entity Type:Organization
Organization Name:SONORA COMMUNITY HOSPITAL
Other - Org Name:ADVENTIST HEALTH SONORA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-536-5011
Mailing Address - Street 1:PO BOX 888852
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90088-8852
Mailing Address - Country:US
Mailing Address - Phone:209-536-3900
Mailing Address - Fax:209-536-2774
Practice Address - Street 1:1000 GREENLEY RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5200
Practice Address - Country:US
Practice Address - Phone:209-536-5000
Practice Address - Fax:209-536-2774
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SONORA COMMUNITY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-17
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000094282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP40335FMedicaid
CAZZR00335FMedicaid
CAZZZC5502ZOtherBLUE CROSS/BLUE SHIELD
CAHSP40335FMedicaid
CACU0092Medicare PIN
CAZZZ22859ZMedicare PIN
CA050335Medicare PIN
CAZZR00335FMedicaid
CAZZZ34300ZMedicare PIN