Healthcare Provider Details

I. General information

NPI: 1295184117
Provider Name (Legal Business Name): LIVINGSTON COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W LAS PALMAS AVE STE E
PATTERSON CA
95363-8873
US

IV. Provider business mailing address

1140 MAIN ST
LIVINGSTON CA
95334-1257
US

V. Phone/Fax

Practice location:
  • Phone: 209-394-7913
  • Fax: 209-394-9093
Mailing address:
  • Phone: 209-394-7913
  • Fax: 209-394-9093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LESLIE TAMIKO MCGOWAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MPH
Phone: 209-394-7913