1073055612 NPI number — GOLDEN STATE URGENT CARE PROVIDERS A MEDICAL CORPORATION

Table of content: (NPI 1073055612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073055612 NPI number — GOLDEN STATE URGENT CARE PROVIDERS A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GOLDEN STATE URGENT CARE PROVIDERS A MEDICAL CORPORATION
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:
1073055612
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MARYLAND FARMS
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-5006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-372-3359
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1487 LANDESS AVE
Provider Second Line Business Practice Location Address:
SUITE 1481
Provider Business Practice Location Address City Name:
MILPITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95035-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-416-5371
Provider Business Practice Location Address Fax Number:
408-262-1031
Provider Enumeration Date:
11/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WOODWARD-SMITH
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
720-446-5890

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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