1730312638 NPI number — PACIFIC HEART & VASCULAR MEDICAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730312638 NPI number — PACIFIC HEART & VASCULAR MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PACIFIC HEART & VASCULAR MEDICAL GROUP
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:
1730312638
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2009
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:
STE. D400
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:
877-835-7938
Provider Business Mailing Address Fax Number:
209-464-1537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15810 S HARLAN RD
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
LATHROP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95330-8719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-464-3615
Provider Business Practice Location Address Fax Number:
209-464-1311
Provider Enumeration Date:
08/26/2009

Additional Information

Authorized Official

Authorized Official Last Name:
STENZLER
Authorized Official First Name:
LEE
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER/PARTNER
Authorized Official Telephone Number:
209-464-3615

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  09-2629 , 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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