Provider Demographics
NPI:1891811907
Name:HAZEL HAWKINS MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:HAZEL HAWKINS MEMORIAL HOSPITAL
Other - Org Name:HAZEL HAWKINS HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASILLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-636-2604
Mailing Address - Street 1:911 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-5602
Mailing Address - Country:US
Mailing Address - Phone:831-637-5711
Mailing Address - Fax:831-637-3126
Practice Address - Street 1:301 THE ALAMEDA
Practice Address - Street 2:SUITE B3
Practice Address - City:SAN JUAN BAUTISTA
Practice Address - State:CA
Practice Address - Zip Code:95045-9746
Practice Address - Country:US
Practice Address - Phone:831-623-4615
Practice Address - Fax:831-623-4689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070000004261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08590FMedicaid
CA058590Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC