1679023980 NPI number — COUNTY OF SAN JOAQUIN

Table of content: (NPI 1679023980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679023980 NPI number — COUNTY OF SAN JOAQUIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF SAN JOAQUIN
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:
SAN JOAQUIN COUNTY CLINIC HAZELTON
Provider Other Organization Name Type Code:
3
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:
1679023980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1020
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95201-3120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-468-6937
Provider Business Mailing Address Fax Number:
209-468-7042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 E HAZELTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95205-6229
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-468-6937
Provider Business Practice Location Address Fax Number:
209-468-7042
Provider Enumeration Date:
10/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JOMAOAS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
B
Authorized Official Title or Position:
DIRECTOR OF AMBULATORY CARE SERVICE
Authorized Official Telephone Number:
209-468-6160

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X , with the licence number:  030000087 , 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)





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