=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073693651
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURPRISE VALLEY HEALTH CARE DISTRICT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 09/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 745 MAIN STREET
-----------------------------------------------------
City | CEDARVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-279-6111
-----------------------------------------------------
Fax | 530-279-2680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 246
-----------------------------------------------------
City | CEDARVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96104-0246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-279-6111
-----------------------------------------------------
Fax | 530-279-2680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | WANDA L GROVE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-279-6111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | 230000025
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------