Healthcare Provider Details

I. General information

NPI: 1164886040
Provider Name (Legal Business Name): PEACH TREE HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3810 ROSIN CT SUITE 100
SACRAMENTO CA
95834-1656
US

IV. Provider business mailing address

1114 YUBA ST STE 220
MARYSVILLE CA
95901-4838
US

V. Phone/Fax

Practice location:
  • Phone: 530-741-6245
  • Fax: 530-741-9274
Mailing address:
  • Phone: 530-749-3242
  • Fax: 530-749-3248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number030000463
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. GREG S STONE
Title or Position: CEO
Credential:
Phone: 530-741-6245