Healthcare Provider Details

I. General information

NPI: 1295727287
Provider Name (Legal Business Name): M A C T HEALTH BOARD INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12140/12150 NEW YORK RANCH RD
JACKSON CA
95642-9407
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-257-2400
  • Fax: 209-257-2403
Mailing address:
  • Phone: 209-754-6262
  • Fax: 209-754-6274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JOHN ALEXANDER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 209-754-6262