Provider Demographics
NPI:1336174564
Name:ST. JOSEPH HOSPITAL EUREKA WILLOW CREEK FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:ST. JOSEPH HOSPITAL EUREKA WILLOW CREEK FAMILY HEALTH CENTER
Other - Org Name:WILLOW CREEK FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:DEN OUDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-629-3111
Mailing Address - Street 1:PO BOX 726
Mailing Address - Street 2:38883 HWY 299
Mailing Address - City:WILLOW CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95573-0726
Mailing Address - Country:US
Mailing Address - Phone:530-629-3111
Mailing Address - Fax:530-629-3122
Practice Address - Street 1:38883 HWY 299
Practice Address - Street 2:
Practice Address - City:WILLOW CREEK
Practice Address - State:CA
Practice Address - Zip Code:95573-0726
Practice Address - Country:US
Practice Address - Phone:530-629-3111
Practice Address - Fax:530-629-3122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM03886GMedicaid
CABCP03886GMedicaid
CABCP03886GMedicaid
CARHM03886GMedicaid