Healthcare Provider Details

I. General information

NPI: 1003863622
Provider Name (Legal Business Name): PEACH TREE HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 PACKARD AVE SUITE 500
MARYSVILLE CA
95901-7118
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: 530-749-3238
Mailing address:
  • Phone: 530-749-3242
  • Fax: 530-749-3248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number550000005
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14393
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18608
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY10876
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS12778
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14503TLG
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberA66235
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA368140
License Number StateCA
# 9
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA93985
License Number StateCA
# 10
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA104819
License Number StateCA
# 11
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA60310
License Number StateCA
# 12
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG42749
License Number StateCA
# 13
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2OA5572
License Number StateCA
# 14
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE1137
License Number StateCA
# 15
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

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