Healthcare Provider Details

I. General information

NPI: 1194340794
Provider Name (Legal Business Name): GREENVILLE RANCHERIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13545 SAINT MARYS AVE
RED BLUFF CA
96080-8884
US

IV. Provider business mailing address

PO BOX 279
GREENVILLE CA
95947-0279
US

V. Phone/Fax

Practice location:
  • Phone: 530-528-8600
  • Fax: 530-528-8612
Mailing address:
  • Phone: 530-528-3481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTONIA LOUISE HAYWORTH
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 530-528-8600