Healthcare Provider Details

I. General information

NPI: 1255595484
Provider Name (Legal Business Name): MATHIESEN MEMORIAL HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 07/25/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18144 SECO ST
JAMESTOWN CA
95327-9737
US

IV. Provider business mailing address

PO BOX 535
JAMESTOWN CA
95327-0535
US

V. Phone/Fax

Practice location:
  • Phone: 209-984-4820
  • Fax: 209-984-4825
Mailing address:
  • Phone: 209-984-4820
  • Fax: 209-984-4825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE KISS
Title or Position: CREDENTIALING
Credential:
Phone: 254-760-0228