NPIMap

Organization Active NPI

Peach Tree Healthcare

Doing business as Peach Tree Clinic

  • Federally Qualified Health Center (FQHC)
  • Marysville, CA
National Provider Identifier
1003863622
Registry record updated May 23, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
550000005 Issued in CA
Legal business name
PEACH TREE HEALTHCARE
Doing business as
Peach Tree Clinic
Practice address
5730 Packard Ave
Suite 500
Marysville, CA 95901-7118
Phone
(530) 749-3242
Fax
(530) 749-3238
NPI assigned
May 28, 2006
Last updated
May 23, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 23, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Greg Stone
Title
Ceo
Phone
(530) 741-6245

Specialties & licenses 15

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 550000005 CA Primary
Physician Assistant 363A00000X PA14393 CA
Nurse Practitioner 363L00000X 18608 CA
Psychologist 103T00000X PSY10876 CA
Clinical Social Worker 1041C0700X LCS12778 CA
Optometrist 152W00000X 14503TLG CA
Acupuncturist 171100000X A66235 CA
Sports Medicine (Family Medicine) Physician 207QS0010X A368140 CA
Obstetrics & Gynecology Physician 207V00000X A93985 CA
Ophthalmology Physician 207W00000X A104819 CA
Pediatrics Physician 208000000X A60310 CA
Psychiatry Physician 2084P0800X G42749 CA
General Practice Physician 208D00000X 2OA5572 CA
Podiatrist 213E00000X E1137 CA
Case Manager/Care Coordinator 171M00000X NU

Addresses

Primary practice location

5730 Packard Ave
Suite 500
Marysville, CA 95901-7118

Mailing address

1114 Yuba St Ste 220
Marysville, CA 95901-4838
Phone (530) 749-3242

Other identifiers 1

IdentifierTypeStateIssuer
FHC11619GMedicaidCA

Other names 1

  • Peach Tree Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20061011000714 CA Part A Provider - Federally Qualified Health Center (FQHC) 7416978440 Practice locations: Marysville, CA
O20101104000566 CA Part B Supplier - Clinic/Group Practice 7416978440 Receives reassigned benefits from 61 practitioners
13 other NPIs on this enrollment
Practice locations: Olivehurst, CA; Yuba City, CA; Sacramento, CA; Marysville, CA; Live Oak, CA; Chico, CA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1003863622. Details of each certification follow.

Federally qualified health center certification: CCN 551833

Legal name
PEACH TREE HEALTHCARE
Doing business as
PEACH TREE CLINIC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Oct 23, 1996
Last certification
Oct 23, 1996
Ownership / control type
Non-profit – corporation
Most recent change of ownership
Feb 22, 2005 (1 total)
Organization structure
CorporationNon-profit
Incorporated
Dec 21, 1995 in CA
Enrollment address
5730 Packard Ave 500
Marysville, CA 95901-7119

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 8

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

Ownership & related parties

All disclosed owners & managing parties 15

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Veronica Avila Individual W-2 Managing EmployeeController Jun 1, 2004
Leanne Link Individual Corporate DirectorBoard Secretary/Treasurer Mar 27, 2025
Robert Bendorf Individual Corporate DirectorBoard Vice Chair May 24, 2024
Emilio Flores Individual Corporate DirectorBoard Member Oct 9, 2025
Monika Lee Individual Corporate DirectorBoard Member Aug 29, 2024
Michelle Woodard Individual Corporate OfficerCoo Dec 3, 2024
W-2 Managing EmployeeAd; Jun 1, 2016
Ngoc-Phuong T Luu Individual Corporate DirectorBoard Member Apr 1, 2020
Renick House Individual Corporate DirectorBoard Member Feb 27, 2025
Chundeep Sidhu Individual Corporate DirectorBoard Member Sep 25, 2025
Tracie Riggs Individual Corporate OfficerCeo Feb 27, 2025
Gregory Barker Individual Corporate OfficerCfo Mar 13, 2025
Erika Laine Summers Individual Corporate DirectorBoard Chair Jul 1, 2020
Awni Allababidi Individual Corporate DirectorBoard Member Oct 1, 2017
Edward Anthony Kalpas Individual Corporate OfficerCmo Nov 10, 2025
Donald Blaser Individual Corporate DirectorBoard Member Feb 1, 2021

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Peach Tree North SacramentoSacramento, CA, CCN 751916 Federally qualified health center Operational/Managerial Control Jul 10, 2012
Peach Tree HealthcareYuba City, CA, CCN 921009 Federally qualified health center Operational/Managerial Control Feb 1, 2017

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 77

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 77

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148774400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1653264000000",
    "number": "1003863622",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1114 YUBA ST STE 220",
            "city": "MARYSVILLE",
            "state": "CA",
            "postal_code": "959014838",
            "telephone_number": "530-749-3242",
            "fax_number": "530-749-3248"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5730 PACKARD AVE",
            "address_2": "SUITE 500",
            "city": "MARYSVILLE",
            "state": "CA",
            "postal_code": "959017118",
            "telephone_number": "530-749-3242",
            "fax_number": "530-749-3238"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEACH TREE HEALTHCARE",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-28",
        "last_updated": "2022-05-23",
        "certification_date": "2022-05-23",
        "status": "A",
        "authorized_official_last_name": "STONE",
        "authorized_official_first_name": "GREG",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "530-741-6245",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "CA",
            "license": "550000005",
            "primary": true
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "CA",
            "license": "PA14393",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner",
            "state": "CA",
            "license": "18608",
            "primary": false
        },
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "CA",
            "license": "PSY10876",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "CA",
            "license": "LCS12778",
            "primary": false
        },
        {
            "code": "152W00000X",
            "taxonomy_group": "",
            "desc": "Optometrist",
            "state": "CA",
            "license": "14503TLG",
            "primary": false
        },
        {
            "code": "171100000X",
            "taxonomy_group": "",
            "desc": "Acupuncturist",
            "state": "CA",
            "license": "A66235",
            "primary": false
        },
        {
            "code": "207QS0010X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Sports Medicine",
            "state": "CA",
            "license": "A368140",
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "CA",
            "license": "A93985",
            "primary": false
        },
        {
            "code": "207W00000X",
            "taxonomy_group": "",
            "desc": "Ophthalmology",
            "state": "CA",
            "license": "A104819",
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "CA",
            "license": "A60310",
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": "CA",
            "license": "G42749",
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "",
            "desc": "General Practice",
            "state": "CA",
            "license": "2OA5572",
            "primary": false
        },
        {
            "code": "213E00000X",
            "taxonomy_group": "",
            "desc": "Podiatrist",
            "state": "CA",
            "license": "E1137",
            "primary": false
        },
        {
            "code": "171M00000X",
            "taxonomy_group": "",
            "desc": "Case Manager/Care Coordinator",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FHC11619G",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peach Tree Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Peach Tree Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Marysville, CA

Sources for this page

Verify at the official NPI Registry.