1962426643 NPI number — CENTER FOR SIGHT OF STOCKTON A MEDICAL CORPORATION

Table of content: (NPI 1962426643)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962426643 NPI number — CENTER FOR SIGHT OF STOCKTON A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR SIGHT OF STOCKTON 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:
1962426643
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1899 W. MARCH LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STOCKTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95207-6402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-623-4700
Provider Business Mailing Address Fax Number:
209-623-4713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1208 FLOYD AVE BLDG D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95350-2470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-622-2700
Provider Business Practice Location Address Fax Number:
209-622-2710
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EDINGTON
Authorized Official First Name:
PHILIP
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
209-948-5515

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ23858Z . This is a "GROUP PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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