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2415 W Vine St Suite 103 Lodi CA 95242-3731 | |
(209) 333-3030 | |
(209) 339-7659 |
Full Name | |
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Speciality | Clinic/center |
Location | 2415 W Vine St, Lodi, California |
Authorized Official Name and Position | Jason Whitney (FINANCE OFFICER) |
Authorized Official Contact | 2093397477 |
Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
Mailing Address | Practice Location Address |
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Po Box 884577 Los Angeles CA 90088-4577 Ph: (209) 334-3411 | 2415 W Vine St Suite 103 Lodi CA 95242-3731 Ph: (209) 333-3030 |
NPI Number | 1811907512 |
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Provider Enumeration Date | 08/08/2006 |
Last Update Date | 01/06/2022 |
Identifier | Type | State | Issuer |
---|---|---|---|
1811907512 | NPI | - | NPPES |
ZZZ78517Z | Medicaid | CA | |
ZZZ78517Z | Other | CA | BLUE SHIELD |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261Q00000X | Clinic/center | 030000056 (California) | Primary |
282N00000X | General Acute Care Hospital | (* (Not Available)) | Secondary |
Inpatient Services Of California, Inc., A Medical Corporation Primary Care Clinic Medicare: Not Enrolled in Medicare Practice Location: 975 S. Fairmont Ave, Lodi, CA 95240 Phone: 214-712-2400 |