Provider Demographics
NPI:1588725196
Name:MARK TWAIN MEDICAL CENTER
Entity type:Organization
Organization Name:MARK TWAIN MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:OCHOA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-467-6442
Mailing Address - Street 1:768 MOUNTAIN RANCH RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9707
Mailing Address - Country:US
Mailing Address - Phone:209-785-7000
Mailing Address - Fax:209-785-7025
Practice Address - Street 1:430 SAWMILL CREEK RD
Practice Address - Street 2:
Practice Address - City:COPPEROPOLIS
Practice Address - State:CA
Practice Address - Zip Code:95228
Practice Address - Country:US
Practice Address - Phone:209-785-0000
Practice Address - Fax:209-785-7085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK TWAIN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-13
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000058261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherWPS TRICARE
=========OtherIRS - TAX ID
CARHM08548FMedicaid
ZZZ61268ZOtherBLUE SHIELD OF CA
CA058548Medicare Oscar/Certification