Healthcare Provider Details

I. General information

NPI: 1538180245
Provider Name (Legal Business Name): HEALTH AND LIFE ORGANIZATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 DEL PASO BLVD
SACRAMENTO CA
95815-3102
US

IV. Provider business mailing address

2200 DEL PASO BLVD
SACRAMENTO CA
95815-3102
US

V. Phone/Fax

Practice location:
  • Phone: 916-924-7988
  • Fax: 916-924-7989
Mailing address:
  • Phone: 916-924-7988
  • Fax: 916-924-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA36371
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. JERRY T BLIATOUT
Title or Position: ADMINISTRATOR
Credential: J.D.
Phone: 916-428-3788