1114014289 NPI number — CHOICE MEDICAL CLINIC, INC.

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 1114014289 NPI number — CHOICE MEDICAL CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE 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:
6
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:
1114014289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1834 STONE AVE
Provider Second Line Business Mailing Address:
SUITE 2B
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95125-1306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-995-0102
Provider Business Mailing Address Fax Number:
408-995-0190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2322 BUTANO DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95825-0629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-483-2885
Provider Business Practice Location Address Fax Number:
916-483-4036
Provider Enumeration Date:
10/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAPIA VAUGHAN
Authorized Official First Name:
LIZA
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
408-995-0102

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  GR0006546 , 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: GR0006546 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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