=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740530385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIDEOUT MEDICAL ASSOCIATES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2012
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 945 SHASTA ST STE 150
-----------------------------------------------------
City | YUBA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95991-4124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-751-5140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3067
-----------------------------------------------------
City | YUBA CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95992-3067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-751-4044
-----------------------------------------------------
Fax | 530-751-4226
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRATARY
-----------------------------------------------------
Name | CHRIS CHAMPLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-751-4242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------