Healthcare Provider Details

I. General information

NPI: 1316096894
Provider Name (Legal Business Name): PEACH TREE HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 LIVE OAK BLVD
LIVE OAK CA
95953-2334
US

IV. Provider business mailing address

1114 YUBA ST STE 220
MARYSVILLE CA
95901-4838
US

V. Phone/Fax

Practice location:
  • Phone: 530-749-3242
  • Fax: 530-749-3248
Mailing address:
  • Phone: 530-749-3242
  • Fax: 530-749-3248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14503TLG
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC51576
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA93985
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550000248
License Number StateCA

VIII. Authorized Official

Name: MR. GREG STONE
Title or Position: CEO
Credential:
Phone: 530-741-6245