Provider Demographics
NPI:1144313024
Name:COUNTY OF PLACER
Entity type:Organization
Organization Name:COUNTY OF PLACER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-886-2910
Mailing Address - Street 1:11583 C AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95603-2703
Mailing Address - Country:US
Mailing Address - Phone:530-889-7215
Mailing Address - Fax:530-889-7280
Practice Address - Street 1:11583 C AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2703
Practice Address - Country:US
Practice Address - Phone:530-889-7215
Practice Address - Fax:530-889-7280
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLACER COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-02
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000494251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR006770Medicaid
CAFLU11119FOtherMEDICARE FLU ROSTER BILLING
CAZZZ92809ZOtherBLUE SHIELD
CARHM53810FMedicaid
CAZZZ92809ZOtherNATIONAL HERITAGE LABS (NHIC)
CARHM53810FMedicaid