Healthcare Provider Details

I. General information

NPI: 1063456903
Provider Name (Legal Business Name): COMMUNITY MEMORIAL HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 TELEPHONE RD
VENTURA CA
93003-5210
US

IV. Provider business mailing address

2705 LOMA VISTA RD SUITE 205
VENTURA CA
93003-1581
US

V. Phone/Fax

Practice location:
  • Phone: 805-643-1871
  • Fax: 805-639-0786
Mailing address:
  • Phone: 805-667-2801
  • Fax: 805-667-2865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY K WILDE
Title or Position: CEO
Credential:
Phone: 805-652-5011