Provider Demographics
NPI:1063430916
Name:DEL PUERTO HEALTH CARE DISTRICT
Entity type:Organization
Organization Name:DEL PUERTO HEALTH CARE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-892-8781
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:PATTERSON
Mailing Address - State:CA
Mailing Address - Zip Code:95363-0187
Mailing Address - Country:US
Mailing Address - Phone:209-892-8781
Mailing Address - Fax:209-892-3755
Practice Address - Street 1:1700 KEYSTONE PACIFIC PKWY
Practice Address - Street 2:UNIT B
Practice Address - City:PATTERSON
Practice Address - State:CA
Practice Address - Zip Code:95363-8874
Practice Address - Country:US
Practice Address - Phone:209-892-9100
Practice Address - Fax:209-892-9102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08901FMedicaid
058901Medicare UPIN
CA058901Medicare UPIN