Healthcare Provider Details

I. General information

NPI: 1154646982
Provider Name (Legal Business Name): ADVENTIST HEALTH CALIFORNIA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 04/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15322 LAKESHORE DR SUITE 203
CLEARLAKE CA
95422-9814
US

IV. Provider business mailing address

1572 RAILROAD AVE SUITE 2
SAINT HELENA CA
94574-1169
US

V. Phone/Fax

Practice location:
  • Phone: 707-968-2809
  • Fax: 707-963-9185
Mailing address:
  • Phone: 707-968-2809
  • Fax: 707-963-9185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberC32535
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA106559
License Number StateCA

VIII. Authorized Official

Name: KAYE A DONNELLY
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 707-968-2809