Provider Demographics
NPI:1194189654
Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Entity type:Organization
Organization Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:3300 RENNER DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-3120
Mailing Address - Country:US
Mailing Address - Phone:707-269-4263
Mailing Address - Fax:
Practice Address - Street 1:3302 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540
Practice Address - Country:US
Practice Address - Phone:707-725-3318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. JOSEPH HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-11
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1194189654Medicaid