Healthcare Provider Details

I. General information

NPI: 1871539783
Provider Name (Legal Business Name): VA NORTHERN CALIFORNIA HEALTH CARE SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5342 DUDLEY BLVD
MCCLELLAN CA
95652-1012
US

IV. Provider business mailing address

5342 DUDLEY BLVD
MCCLELLAN CA
95652-1012
US

V. Phone/Fax

Practice location:
  • Phone: 916-561-7520
  • Fax: 916-561-7529
Mailing address:
  • Phone: 916-561-7520
  • Fax: 916-561-7529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberKY 3114
License Number StateKY

VIII. Authorized Official

Name: MRS. GERARDA W PERSAD
Title or Position: SOCIAL WORKER
Credential: MSSW, LCSW
Phone: 916-561-7520