Provider Demographics
NPI:1336367515
Name:SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT
Entity Type:Organization
Organization Name:SOUTHERN HUMBOLDT COMMUNITY HEALTHCARE DISTRICT
Other - Org Name:SOUTHERN HUMBOLDT COMMUNITY HOSPITAL DISTRICT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MED STAFF COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-923-3921
Mailing Address - Street 1:733 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:GARBERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95542-3201
Mailing Address - Country:US
Mailing Address - Phone:707-923-3921
Mailing Address - Fax:707-923-1456
Practice Address - Street 1:509 ELM ST
Practice Address - Street 2:
Practice Address - City:GARBERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95542-3204
Practice Address - Country:US
Practice Address - Phone:707-923-3921
Practice Address - Fax:707-923-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000052261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ174988Medicaid
OR272260Medicaid
CARHM03921GOtherMEDI-CAL
WA3003993Medicaid
CAZZZ05354ZOtherBLUE SHIELD CLINIC
WA3003993Medicaid
CAZZZ42835ZMedicare PIN