Healthcare Provider Details

I. General information

NPI: 1013882877
Provider Name (Legal Business Name): GREENVILLE RANCHERIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2638 EDITH AVE
REDDING CA
96001-3043
US

IV. Provider business mailing address

2638 EDITH AVE
REDDING CA
96001-3043
US

V. Phone/Fax

Practice location:
  • Phone: 530-244-7192
  • Fax: 530-244-4185
Mailing address:
  • Phone: 530-244-7192
  • Fax: 530-244-4185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

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