Healthcare Provider Details

I. General information

NPI: 1558800243
Provider Name (Legal Business Name): COLUSA MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 E WEBSTER ST
COLUSA CA
95932-2954
US

IV. Provider business mailing address

700 17TH ST STE 201D
MODESTO CA
95354-1249
US

V. Phone/Fax

Practice location:
  • Phone: 530-458-1808
  • Fax:
Mailing address:
  • Phone: 530-458-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code315D00000X
TaxonomyInpatient Hospice
License Number
License Number State

VIII. Authorized Official

Name: TAMMY JEAN THOMPSON
Title or Position: VP FINANCE
Credential:
Phone: 209-248-7851