Provider Demographics
NPI:1750773792
Name:CENTURION VALLEY HEALTHCARE INC.
Entity type:Organization
Organization Name:CENTURION VALLEY HEALTHCARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HTAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-910-0701
Mailing Address - Street 1:6337 BROOK HOLLOW CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2441
Mailing Address - Country:US
Mailing Address - Phone:209-910-0701
Mailing Address - Fax:209-910-9763
Practice Address - Street 1:6337 BROOK HOLLOW CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2441
Practice Address - Country:US
Practice Address - Phone:209-910-0701
Practice Address - Fax:209-910-9763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-27
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992765523Medicaid
CA1992765523Medicaid