=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285215400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M A C T HEALTH BOARD INCORPORATED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2021
-----------------------------------------------------
Last Update Date | 06/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 PRESTON AVE
-----------------------------------------------------
City | IONE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95640-9158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-754-6262
-----------------------------------------------------
Fax | 209-754-6275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 939
-----------------------------------------------------
City | ANGELS CAMP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95222-0939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-754-6262
-----------------------------------------------------
Fax | 209-754-6275
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JOHN SHAWVER ALEXANDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 209-754-6258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------