Healthcare Provider Details

I. General information

NPI: 1699759332
Provider Name (Legal Business Name): UKIAH VALLEY PRIMARY CARE MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 06/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 HOSPITAL DR. STE. 207
UKIAH CA
95482-4533
US

IV. Provider business mailing address

PO BOX 2739
UKIAH CA
95482-2739
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-8000
  • Fax: 707-462-1111
Mailing address:
  • Phone: 707-463-8000
  • Fax: 707-462-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEREMY MANN
Title or Position: PRESIDENT, BOARD OF DIRECTORS
Credential: M.D.
Phone: 707-463-8000