Healthcare Provider Details

I. General information

NPI: 1700117462
Provider Name (Legal Business Name): SOUTHERN MONO HEALTH CARE DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 01/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SIERRA PARK ROAD
MAMMOTH LAKES CA
93546-0660
US

IV. Provider business mailing address

PO BOX 660
MAMMOTH LAKES CA
93546-0660
US

V. Phone/Fax

Practice location:
  • Phone: 760-872-6749
  • Fax: 760-872-6790
Mailing address:
  • Phone: 760-872-6749
  • Fax: 760-872-6790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number240000008
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number240000008
License Number StateCA

VIII. Authorized Official

Name: MR. GARY BOYD
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 760-934-3311