Healthcare Provider Details

I. General information

NPI: 1063875128
Provider Name (Legal Business Name): ALEXANDER VALLEY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TARMAN DR
CLOVERDALE CA
95425-3932
US

IV. Provider business mailing address

106 E 1ST ST
CLOVERDALE CA
95425-3746
US

V. Phone/Fax

Practice location:
  • Phone: 707-894-4229
  • Fax: 707-894-2954
Mailing address:
  • Phone: 707-669-1780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number95002663
License Number StateCA

VIII. Authorized Official

Name: PATRICK RICHARDS
Title or Position: CONTROLLER
Credential:
Phone: 707-669-1780