Provider Demographics
NPI:1922598226
Name:PEACH TREE HEALTHCARE
Entity Type:Organization
Organization Name:PEACH TREE HEALTHCARE
Other - Org Name:PEACH TREE VISION CHICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:530-749-3242
Mailing Address - Street 1:1114 YUBA ST STE 220
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-4838
Mailing Address - Country:US
Mailing Address - Phone:530-749-3242
Mailing Address - Fax:530-749-3248
Practice Address - Street 1:114 MISSION RANCH BLVD STE 50
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-5137
Practice Address - Country:US
Practice Address - Phone:530-749-3242
Practice Address - Fax:530-749-3248
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEACH TREE HEALTHCARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-14
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55000248261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA751978Medicaid