Healthcare Provider Details

I. General information

NPI: 1083015481
Provider Name (Legal Business Name): WAL-MART ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 MADISON AVE
CARMICHAEL CA
95608-0521
US

IV. Provider business mailing address

6005 MADISON AVE
CARMICHAEL CA
95608-0521
US

V. Phone/Fax

Practice location:
  • Phone: 916-534-1162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number64873
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number64873
License Number StateCA

VIII. Authorized Official

Name: CARLA BROWN
Title or Position: MARKET HEALTH WELLNESS DIRECTOR
Credential:
Phone: 479-899-5685