Mangrove Medical Group

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

MANGROVE MEDICAL GROUP

Practice address

1040 Mangrove Ave
Chico, CA 95926-3509

Phone

(530) 345-0064

Fax

(530) 345-0680

NPI assigned

Oct 21, 2005

Reactivated

Jan 4, 2022

Organization subpart

No

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

Authorized official

Name

Elizabeth A Mullins

Title

Administrator

Phone

(530) 345-0064

Specialties & licenses 8

Addresses

Other identifiers 1

Other names 1

• Mangrove Lab & XRay Other name

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/15385/brand/1/csg/1/fhir/r4

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Robert Stephen Avilla, D.O.

  • Family Medicine Physician
  • Chico, CA
  • NPI 1346687225
  Medicare reassignment Care Compare group
• Kurt E Johnson, M.D., INC.

  • General Practice Physician
  • Chico, CA
  • NPI 1407881741
  Medicare reassignment Care Compare group
• Barbara Jean Kinkle, PA-C

  • Physician Assistant
  • Redlands, CA
  • NPI 1104262757
  Medicare reassignment Care Compare group
• Heidi Natalie McMillin, FNP-C

  • Family Nurse Practitioner
  • Chico, CA
  • NPI 1750995924
  Medicare reassignment Care Compare group
• Laura Schiff

  • Family Nurse Practitioner
  • Chico, CA
  • NPI 1558904177
  Medicare reassignment Care Compare group
• Emilyann Prybella Schultz, NP

  • Nurse Practitioner
  • Chico, CA
  • NPI 1427737931
  Medicare reassignment Care Compare group
• Joshua Schultz, FNP - BC

  • Family Nurse Practitioner
  • Chico, CA
  • NPI 1114884756
  Medicare reassignment Care Compare group
• Kevin R Sorensen, DO

  • General Practice Physician
  • Chico, CA
  • NPI 1144680141
  Medicare reassignment Care Compare group
• Stephen Anthony Vannucci, MD

  • Dermatopathology Physician
  • Chico, CA
  • NPI 1255405783
  Medicare reassignment Care Compare group
• Randall S Williams, MD

  • General Practice Physician
  • Chico, CA
  • NPI 1245261114
  Medicare reassignment Care Compare group

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

{
    "created_epoch": "1129852800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1641254400000",
    "number": "1326038381",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1040 MANGROVE AVE",
            "city": "CHICO",
            "state": "CA",
            "postal_code": "959263509",
            "telephone_number": "530-345-0064",
            "fax_number": "530-345-0680"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1040 MANGROVE AVE",
            "city": "CHICO",
            "state": "CA",
            "postal_code": "959263509",
            "telephone_number": "530-345-0064",
            "fax_number": "530-345-0680"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MANGROVE MEDICAL GROUP",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-10-21",
        "last_updated": "2022-01-04",
        "certification_date": "2022-01-04",
        "deactivation_date": "2021-12-16",
        "reactivation_date": "2022-01-04",
        "status": "A",
        "authorized_official_last_name": "MULLINS",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "530-345-0064"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207ND0900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "CA",
            "license": null,
            "primary": true
        },
        {
            "code": "207VG0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Obstetrics & Gynecology, Gynecology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": "CA",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR0206X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Radiology, Mammography",
            "state": "CA",
            "license": "RHC 110619",
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "CA",
            "license": "05DO644223",
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "CA",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "470000743",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Mangrove Lab & XRay",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Mangrove Lab & XRay",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• Nicholas Malone, MA MFT
• Danyell Yvonne Maloney
• Georgina E Maltby, PHD
• Ahmed Mamane, RPH
• Brenda Lee Mamich
• Mackenzie Noelle Mankin
• Kristen Manning, FNP
• Faailo Manogiamanu
• Martin Manzella Jr., DENTIST
• Mara Varnell-Christensen Marriage and Family Therapist Inc.

• Family Medicine Physician in Chico, CA
• Providers in Chico, CA by specialty
• Family Medicine Physician in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.