1013030006 NPI number — DELTA HEART & MEDICAL CLINIC, INC.

Table of content: (NPI 1013030006)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013030006 NPI number — DELTA HEART & MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DELTA HEART & MEDICAL CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013030006
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 E MARCH LN
Provider Second Line Business Mailing Address:
A-170
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95210-6629
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-951-9884
Provider Business Mailing Address Fax Number:
209-951-7873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 E MARCH LN
Provider Second Line Business Practice Location Address:
A-170
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95210-6629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-951-9884
Provider Business Practice Location Address Fax Number:
209-951-7873
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
OLOWOYEYE
Authorized Official First Name:
BUNMI
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
209-951-9884

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  A48005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X , with the licence number: A48005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC3822 . This is a "RAILROAD MEDICARE PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: OOA480050 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00A480050 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 037196 . This is a "HILL PHYSICIANS MED GROUP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 6923038 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ64420Z . This is a "BLUE SHIELD OF CA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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