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CAH051332-02 Mark Twain Medical Center (Terminated)
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Main Details
Name
Mark Twain Medical Center
Subdivision Name
VALLEY SPRINGS FAMILY MEDICAL CLINIC
Type
Critical Access Hospital
Rural
Yes
340B ID
CAH051332-02
Medicare Provider Number
051332
Outpatient Facility Provider Number
058571
Additional Details
Current Program Status
Terminated
Registration Date
1/14/2013
Participating Start Date
4/1/2013
Participating Approval Date
1/14/2013
Last Recertification Date
8/27/2019
Termination Date
Termination Reason
10/1/2020
Site closure
Contacts
Authorizing Official
Mark Twain Medical Center
Doug Patrick Archer, President/CEO
(209) 754-5916
Primary Contact
Mark Twain Medical Center
Jill Ortiz, Director of Pharmacy
(209) 754-2464
Addresses
Street Address
1919 Vista Del Lago Dr
Valley Springs, CA 95252-9294
Billing Address
Dignity Health AP SAC
3400 Data Drive
Rancho Cordova, CA 95670
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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