1386136430 NPI number — VALLEY RIVER ORTHOPEDICS AND SPORTS MEDICINE

Table of content: (NPI 1386136430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386136430 NPI number — VALLEY RIVER ORTHOPEDICS AND SPORTS MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY RIVER ORTHOPEDICS AND SPORTS MEDICINE
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:
1386136430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
220 STANDIFORD AVE STE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95350-1159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-400-2959
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
VALLEY RIVER ORTHOPEDICS & SPORTS MEDICINE INC
Provider Second Line Business Practice Location Address:
3329 G ST STE A
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-661-4406
Provider Business Practice Location Address Fax Number:
209-400-2752
Provider Enumeration Date:
06/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BEAUCHMAN
Authorized Official First Name:
NASEEM
Authorized Official Middle Name:
N.
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
209-400-2959

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  A123593 , 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: A15220 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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