Healthcare Provider Details

I. General information

NPI: 1396246633
Provider Name (Legal Business Name): COLUSA MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E ST
WILLIAMS CA
95987-5810
US

IV. Provider business mailing address

700 17TH ST STE 201D
MODESTO CA
95354-1249
US

V. Phone/Fax

Practice location:
  • Phone: 530-619-0800
  • Fax: 530-619-0897
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMMY THOMPSON
Title or Position: VP FINANCE/CFO
Credential:
Phone: 209-287-6308