Provider Demographics
NPI:1417505918
Name:M A C T HEALTH BOARD, INCORPORATED
Entity type:Organization
Organization Name:M A C T HEALTH BOARD, INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SHAWVER
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:EXECUTIVE DIRECTOR
Authorized Official - Phone:209-754-6258
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:ANGELS CAMP
Mailing Address - State:CA
Mailing Address - Zip Code:95222-0939
Mailing Address - Country:US
Mailing Address - Phone:209-754-6262
Mailing Address - Fax:
Practice Address - Street 1:52 S MAIN STREET, SUITE B
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222
Practice Address - Country:US
Practice Address - Phone:209-754-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACT HEALTH BOARD, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-08-28
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366519431OtherFQHC