Healthcare Provider Details

I. General information

NPI: 1700282175
Provider Name (Legal Business Name): GOLDEN VALLEY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2014
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 FLORIDA AVENUE
MODESTO CA
95350-4437
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-574-1030
  • Fax: 209-574-1038
Mailing address:
  • Phone: 209-385-5529
  • Fax: 209-383-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number662674
License Number StateCA

VIII. Authorized Official

Name: MR. TONY WEBER
Title or Position: CEO
Credential: CEO
Phone: 209-385-5551