Healthcare Provider Details

I. General information

NPI: 1821041534
Provider Name (Legal Business Name): NORTHERN CALIFORNIA ORTHOPEDIC CENTERS MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 COYLE AVE STE 303
CARMICHAEL CA
95608-6337
US

IV. Provider business mailing address

6620 COYLE AVE STE 303
CARMICHAEL CA
95608-6337
US

V. Phone/Fax

Practice location:
  • Phone: 916-965-4000
  • Fax: 916-965-4813
Mailing address:
  • Phone: 916-965-4000
  • Fax: 916-965-4813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: BREANA WELLS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 916-965-4000