Healthcare Provider Details

I. General information

NPI: 1710172242
Provider Name (Legal Business Name): RIVERSIDE HEALTH CLINIC OF COLUSA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2007
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 BRIDGE ST
COLUSA CA
95932-2851
US

IV. Provider business mailing address

1215 PLUMAS ST SUITE 1900
YUBA CITY CA
95991-3455
US

V. Phone/Fax

Practice location:
  • Phone: 530-458-2300
  • Fax: 530-458-5558
Mailing address:
  • Phone: 530-674-2100
  • Fax: 530-674-2277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA70328
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA51440
License Number StateCA

VIII. Authorized Official

Name: SANJIV K MIDHA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 530-458-2300