Provider Demographics
NPI:1295737401
Name:DOS PALOS MEMORIAL HOSPITAL, INC
Entity type:Organization
Organization Name:DOS PALOS MEMORIAL HOSPITAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-392-6121
Mailing Address - Street 1:2118 MARGUERITE ST
Mailing Address - Street 2:
Mailing Address - City:DOS PALOS
Mailing Address - State:CA
Mailing Address - Zip Code:93620-2339
Mailing Address - Country:US
Mailing Address - Phone:209-392-6121
Mailing Address - Fax:209-392-6881
Practice Address - Street 1:2118 MARGUERITE ST
Practice Address - Street 2:
Practice Address - City:DOS PALOS
Practice Address - State:CA
Practice Address - Zip Code:93620-2339
Practice Address - Country:US
Practice Address - Phone:209-392-6121
Practice Address - Fax:209-392-6881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X314000000X
CA261QR1300X261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55311IMedicaid
CARHM18598FMedicaid
CARHM18598FMedicaid
CA555311Medicare Oscar/Certification