MEDICARE: DOS PALOS MEMORIAL HOSPITAL, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	314000000X	CA
2	261Q00000X	Clinic/Center	261QR1300X	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295737401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOS PALOS MEMORIAL HOSPITAL, INC

Provider Business Mailing Address
First Line	:	2118 MARGUERITE ST
Second Line	:
City	:	DOS PALOS
State	:	CA
Zip	:	93620-2339
Country	:	US
Telephone Number	:	209-392-6121
Fax Number	:	209-392-6881

Provider Business Practice Location Address
First Line	:	2118 MARGUERITE ST
Second Line	:
City	:	DOS PALOS
State	:	CA
Zip	:	93620-2339
Country	:	US
Telephone Number	:	209-392-6121
Fax Number	:	209-392-6881

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RAY E SMITH
Credential	:
Telephone Number	:	209-392-6121

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	03/15/2012

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