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500 Jessie Ave Sacramento CA 95838-2609 | |
| (916) 668-0683 | |
| (888) 719-2432 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 500 Jessie Ave, Sacramento, California |
| Authorized Official Name and Position | Glen L Xiong (CEO) |
| Authorized Official Contact | 9164718838 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2775 18th St Sacramento CA 95818-3005 Ph: (916) 471-8838 | 500 Jessie Ave Sacramento CA 95838-2609 Ph: (916) 668-0683 |
| NPI Number | 1164191417 |
|---|---|
| Provider Enumeration Date | 09/09/2021 |
| Last Update Date | 11/11/2021 |
| Medicare PECOS PAC ID | 5698165975 |
|---|---|
| Medicare Enrollment ID | O20211130001686 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164191417 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | (* (Not Available)) | Primary |
| Provider Name | Glen L Xiong |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1114945102 PECOS PAC ID: 6103829007 Enrollment ID: I20060815000181 |
| Provider Name | Desalegn A Ejigu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1689150716 PECOS PAC ID: 5799035044 Enrollment ID: I20180906002079 |
| Provider Name | Sherry Watts |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1346809316 PECOS PAC ID: 7618309089 Enrollment ID: I20200427001260 |
| Provider Name | Chantel Marie Kilford |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245732635 PECOS PAC ID: 8123473592 Enrollment ID: I20231005001136 |
| Provider Name | Aubrey Hope Bunch Lemire |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1215248075 PECOS PAC ID: 2163967480 Enrollment ID: I20240711000867 |
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