Provider Demographics
NPI:1124300207
Name:LIVINGSTON COMMUNITY HEALTH
Entity type:Organization
Organization Name:LIVINGSTON COMMUNITY HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGOWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:209-394-1365
Mailing Address - Street 1:1140 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1257
Mailing Address - Country:US
Mailing Address - Phone:209-394-7913
Mailing Address - Fax:209-394-9093
Practice Address - Street 1:7970 LANDER AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HILMAR
Practice Address - State:CA
Practice Address - Zip Code:95324-8310
Practice Address - Country:US
Practice Address - Phone:209-262-1819
Practice Address - Fax:209-262-1817
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIVINGSTON COMMUNITY HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-14
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA751057Medicare Oscar/Certification
CA751057Medicare PIN