Healthcare Provider Details

I. General information

NPI: 1215578885
Provider Name (Legal Business Name): GRASSROOTS HEALTHCARE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 PLACER CIR
VACAVILLE CA
95687-7882
US

IV. Provider business mailing address

732 PLACER CIR
VACAVILLE CA
95687-7882
US

V. Phone/Fax

Practice location:
  • Phone: 707-992-5809
  • Fax: 707-210-0480
Mailing address:
  • Phone: 707-992-5809
  • Fax: 707-210-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. JERRY CLINE
Title or Position: MD
Credential: MD
Phone: 707-992-5809