Healthcare Provider Details

I. General information

NPI: 1740336734
Provider Name (Legal Business Name): HEALTH AND LIFE ORGANIZATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7275 E SOUTHGATE DR SUITE 204
SACRAMENTO CA
95823-2628
US

IV. Provider business mailing address

3030 EXPLORER DR
SACRAMENTO CA
95827-2728
US

V. Phone/Fax

Practice location:
  • Phone: 916-428-3788
  • Fax: 916-428-0788
Mailing address:
  • Phone: 916-642-1867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA73749
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

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