Healthcare Provider Details

I. General information

NPI: 1932666575
Provider Name (Legal Business Name): GOLD COUNTRY HEALTH INITIATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820/830 STATE HIGHWAY 88
JACKSON CA
95642
US

IV. Provider business mailing address

PO BOX 4057
STOCKTON CA
95204-0057
US

V. Phone/Fax

Practice location:
  • Phone: 209-610-1524
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ERNEST VASTI
Title or Position: OWNER
Credential: MD
Phone: 209-610-1524