Provider Demographics
NPI:1467444364
Name:M A C T HEALTH BOARD INCORPORATED
Entity type:Organization
Organization Name:M A C T HEALTH BOARD INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-754-6262
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:209-754-6274
Practice Address - Street 1:13975 MONO WAY STE G
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-2824
Practice Address - Country:US
Practice Address - Phone:209-533-9600
Practice Address - Fax:209-533-9608
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:M A C T HEALTH BOARD INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-17
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 261QP2300X, 261QF0400X
CA030000704261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP70875FMedicaid
CAZZZ18354ZMedicare PIN