Healthcare Provider Details

I. General information

NPI: 1326038381
Provider Name (Legal Business Name): MANGROVE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date: 12/16/2021
Reactivation Date: 01/04/2022

III. Provider practice location address

1040 MANGROVE AVE
CHICO CA
95926-3509
US

IV. Provider business mailing address

1040 MANGROVE AVE
CHICO CA
95926-3509
US

V. Phone/Fax

Practice location:
  • Phone: 530-345-0064
  • Fax: 530-345-0680
Mailing address:
  • Phone: 530-345-0064
  • Fax: 530-345-0680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License NumberRHC 110619
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number05DO644223
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: ELIZABETH A MULLINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 530-345-0064