Healthcare Provider Details

I. General information

NPI: 1568449304
Provider Name (Legal Business Name): ANDERSON VALLEY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 AIRPORT ROAD
BOONVILLE CA
95415
US

IV. Provider business mailing address

PO BOX 338
BOONVILLE CA
95415-0338
US

V. Phone/Fax

Practice location:
  • Phone: 707-895-3477
  • Fax: 707-895-2035
Mailing address:
  • Phone: 707-895-3477
  • Fax: 707-895-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number110000165
License Number StateCA

VIII. Authorized Official

Name: SUSAN D SMITH
Title or Position: CEO
Credential: M.D.
Phone: 707-895-3477