1871769000 NPI number — MED CENTER MEDICAL CLINIC, INC

Table of content: (NPI 1871769000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871769000 NPI number — MED CENTER MEDICAL CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MED CENTER 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:
DR CHAMPLIN'S ANNEX
Provider Other Organization Name Type Code:
3
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:
1871769000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6060 SUNRISE VISTA DR
Provider Second Line Business Mailing Address:
STE 3050
Provider Business Mailing Address City Name:
CITRUS HEIGHTS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95610-7053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-676-1450
Provider Business Mailing Address Fax Number:
916-676-1447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7988 CALIFORNIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIR OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95628-7140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-961-7031
Provider Business Practice Location Address Fax Number:
916-961-5218
Provider Enumeration Date:
05/07/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ADGE
Authorized Official First Name:
CINDY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
916-676-1450

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA10071 , 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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