Provider Demographics
NPI:1962444059
Name:SOUTHERN MONO HEALTH CARE DISTRICT
Entity type:Organization
Organization Name:SOUTHERN MONO HEALTH CARE DISTRICT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN WINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-934-3311
Mailing Address - Street 1:PO BOX 660
Mailing Address - Street 2:85 SIERRA PARK RD.
Mailing Address - City:MAMMOTH LAKES
Mailing Address - State:CA
Mailing Address - Zip Code:93546
Mailing Address - Country:US
Mailing Address - Phone:760-934-3311
Mailing Address - Fax:760-924-4149
Practice Address - Street 1:85 SIERRA PARK RD
Practice Address - Street 2:
Practice Address - City:MAMMOTH LAKES
Practice Address - State:CA
Practice Address - Zip Code:93546-2073
Practice Address - Country:US
Practice Address - Phone:760-934-3311
Practice Address - Fax:760-924-4149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240000008261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP30638HMedicaid
CAHAP18523FMedicaid
CARHM18523FMedicaid
CAHSP40638HMedicaid
CAHSP40638HMedicaid
CAZZZ96521ZMedicare PIN