Provider Demographics
NPI:1801973052
Name:SURPRISE VALLEY HEALTH CARE DISTRICT
Entity type:Organization
Organization Name:SURPRISE VALLEY HEALTH CARE DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-279-6111
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:741 NORTH MAIN
Mailing Address - City:CEDARVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96104-0246
Mailing Address - Country:US
Mailing Address - Phone:530-279-6111
Mailing Address - Fax:530-279-2680
Practice Address - Street 1:741 MAIN & WASHINGTON
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:CA
Practice Address - Zip Code:96104-0246
Practice Address - Country:US
Practice Address - Phone:530-279-6111
Practice Address - Fax:530-279-2680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA230000025261QE0002X, 261QR0200X, 282N00000X, 291U00000X, 3416L0300X, 282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No282N00000XHospitalsGeneral Acute Care Hospital
No291U00000XLaboratoriesClinical Medical Laboratory
No3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP30676FMedicaid
CAMTE00309FMedicaid
CAHSP40676FMedicaid
CAZZZ12663ZMedicare ID - Type UnspecifiedNHIC PROVIDER NUMBER
CAHSP40676FMedicaid