Provider Demographics
NPI:1972721793
Name:OLE HEALTH
Entity Type:Organization
Organization Name:OLE HEALTH
Other - Org Name:HANSEN FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACISAAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-767-6435
Mailing Address - Street 1:215 WEST BEAMER ST.
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-753-3498
Mailing Address - Fax:
Practice Address - Street 1:215 WEST BEAMER ST.
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-753-3498
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC11771FMedicaid