Healthcare Provider Details

I. General information

NPI: 1831128073
Provider Name (Legal Business Name): WUNDERLICH BALLOCH AND FUNG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 LAS POSAS RD SUITE 106
CAMARILLO CA
93010-1427
US

IV. Provider business mailing address

3801 LAS POSAS RD SUITE 106
CAMARILLO CA
93010-1427
US

V. Phone/Fax

Practice location:
  • Phone: 805-482-1416
  • Fax: 805-389-3047
Mailing address:
  • Phone: 805-482-1416
  • Fax: 805-389-3047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG77362
License Number StateCA

VIII. Authorized Official

Name: JODY LYNN BALLOCH
Title or Position: OWNER
Credential: MD
Phone: 805-482-1416