Healthcare Provider Details

I. General information

NPI: 1063965952
Provider Name (Legal Business Name): HEALTH FOR ALL - REVERE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

752 REVERE ST UNIT B
SACRAMENTO CA
95818-2073
US

IV. Provider business mailing address

420 I STREET SUITE 7
SACRAMENTO CA
95814-2319
US

V. Phone/Fax

Practice location:
  • Phone: 916-441-2811
  • Fax: 916-441-2876
Mailing address:
  • Phone: 916-441-2811
  • Fax: 916-441-2876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number030000221
License Number StateCA

VIII. Authorized Official

Name: MR. CHUCK WIESEN
Title or Position: CEO
Credential:
Phone: 916-441-2811