=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407898265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUTTER CENTRAL VALLEY HOSPITALS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 12/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 COFFEE ROAD STE. 110
-----------------------------------------------------
City | MODESTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95355-2803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-569-7642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 740152
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90074-0152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-398-1633
-----------------------------------------------------
Fax | 209-569-7362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP SHARED SERVICES
-----------------------------------------------------
Name | MR. BRIAN TRENT HUNTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-297-8555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number | HSP37596
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number | HSP37596
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | HSP37596
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336H0001X
-----------------------------------------------------
Taxonomy Name | Home Infusion Therapy Pharmacy
-----------------------------------------------------
License Number | HSP37596
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 282N00000X
-----------------------------------------------------
Taxonomy Name | General Acute Care Hospital
-----------------------------------------------------
License Number | 030000061
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------