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DSH050301P ADVENTIST HEALTH UKIAH VALLEY (Terminated)
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Main Details
Name
ADVENTIST HEALTH UKIAH VALLEY
Subdivision Name
Outpatient Service, Outpatient Clinic - ENT
Type
Disproportionate Share Hospital
Rural
Yes
340B ID
DSH050301P
Medicare Provider Number
050301
Outpatient Facility Provider Number
Additional Details
Current Program Status
Terminated
Registration Date
1/3/2014
Participating Start Date
4/1/2014
Participating Approval Date
3/5/2014
Last Recertification Date
8/30/2019
Termination Date
Termination Reason
7/1/2020
Site closure
Contacts
Authorizing Official
Adventist Health Ukiah Valley
Judson Howe, Network President
(707) 467-5352
Primary Contact
Adventist Health Ukiah Valley
Tracy Dolmage, Pharmacy Analyst
(707) 463-7633
Addresses
Street Address
1165 South Dora
Suite C2
Ukiah, CA 95482
Billing Address
Same as Street Address
Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
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