Healthcare Provider Details

I. General information

NPI: 1568455053
Provider Name (Legal Business Name): GREENVILLE RANCHERIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 08/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 OAK STREET
RED BLUFF CA
96080-4605
US

IV. Provider business mailing address

P O BOX 279
GREENVILLE CA
95947-0279
US

V. Phone/Fax

Practice location:
  • Phone: 530-528-8600
  • Fax: 530-528-8612
Mailing address:
  • Phone: 530-284-7990
  • Fax: 530-284-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number32161
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number56174
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number59948
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARGARET A ALSPAUGH
Title or Position: EXECUTIVE DIRECTOR
Credential: M.D., PLD
Phone: 530-528-8600