Healthcare Provider Details

I. General information

NPI: 1083330807
Provider Name (Legal Business Name): MENDONOMA HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2022
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39251 CA-1
GUALALA CA
95445
US

IV. Provider business mailing address

PO BOX 1196
GUALALA CA
95445-1196
US

V. Phone/Fax

Practice location:
  • Phone: 707-412-3176
  • Fax: 707-412-3196
Mailing address:
  • Phone: 707-412-3176
  • Fax: 707-412-3196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELINE MARIE WHITE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 707-412-3176