1487848131 NPI number — SAN JOAQUIN PRIME CARE MEDICAL GROUP INC

Table of content: (NPI 1487848131)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487848131 NPI number — SAN JOAQUIN PRIME CARE MEDICAL GROUP INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN JOAQUIN PRIME CARE MEDICAL GROUP 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:
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:
1487848131
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 E PINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EXETER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93221-1838
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-592-2134
Provider Business Mailing Address Fax Number:
559-592-5017

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
682 E VISALIA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMERSVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93223-1641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-594-4564
Provider Business Practice Location Address Fax Number:
559-594-4564
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURGINS
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING SUPERVISOR
Authorized Official Telephone Number:
559-783-1181

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A43893 , 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: RHM53939F , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GR0084781 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com