1962502195 NPI number — SACRAMENTO PEDIATRIC ENDOCRINE AND DIABETES MEDICAL CLINIC INC

Table of content: (NPI 1962502195)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962502195 NPI number — SACRAMENTO PEDIATRIC ENDOCRINE AND DIABETES MEDICAL CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SACRAMENTO PEDIATRIC ENDOCRINE AND DIABETES 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:
1962502195
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:
5301 F ST
Provider Second Line Business Mailing Address:
SUITE 209
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95819-3226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-733-6006
Provider Business Mailing Address Fax Number:
916-454-1446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 F ST
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95819-3226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-733-6006
Provider Business Practice Location Address Fax Number:
916-454-1446
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SHEIKHOLISLAM
Authorized Official First Name:
BAGHER
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
916-733-6006

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  A23623 , 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: A23623 . This is a "LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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