Provider Demographics
NPI:1295044832
Name:HEALTH AND LIFE ORGANIZATION, INC.
Entity type:Organization
Organization Name:HEALTH AND LIFE ORGANIZATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:BLIATOUT
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:916-428-3788
Mailing Address - Street 1:7275 E SOUTHGATE DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2628
Mailing Address - Country:US
Mailing Address - Phone:916-428-3788
Mailing Address - Fax:
Practice Address - Street 1:5524 ASSEMBLY CT
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2625
Practice Address - Country:US
Practice Address - Phone:916-642-1867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-30
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538180245OtherUNSPECIFIED
CA1699082867OtherNPPES
CA1740336734OtherMEDICARE ID