Provider Demographics
NPI:1821149816
Name:SOUTHERN MONO HEALTH CARE DISTRICT
Entity Type:Organization
Organization Name:SOUTHERN MONO HEALTH CARE DISTRICT
Other - Org Name:BRIDGEPORT FAMILY MEDICINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFI
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN WINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-934-3311
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546-0660
Mailing Address - Country:US
Mailing Address - Phone:760-934-3311
Mailing Address - Fax:760-924-4023
Practice Address - Street 1:221 TWIN LAKES ROAD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CA
Practice Address - Zip Code:93517
Practice Address - Country:US
Practice Address - Phone:760-932-7011
Practice Address - Fax:760-932-7180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000008282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058640Medicare Oscar/Certification