Healthcare Provider Details

I. General information

NPI: 1841483427
Provider Name (Legal Business Name): EAG PROFESSIONAL MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2007
Last Update Date: 10/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 CENTRAL AVE STE C
CERES CA
95307-1806
US

IV. Provider business mailing address

3512 HILLGLEN AVE
MODESTO CA
95355-7867
US

V. Phone/Fax

Practice location:
  • Phone: 209-537-4434
  • Fax: 209-551-3255
Mailing address:
  • Phone: 209-985-4813
  • Fax: 209-551-3255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA68296
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA68296
License Number StateCA

VIII. Authorized Official

Name: DR. ELEUTERIO ARCANGEL GO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 209-537-4434