Healthcare Provider Details

I. General information

NPI: 1689614562
Provider Name (Legal Business Name): VALLEY HEART ASSOCIATES MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 FLORIDA AVE STE 100
MODESTO CA
95350-4430
US

IV. Provider business mailing address

1540 FLORIDA AVE STE 100
MODESTO CA
95350-4430
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-5557
  • Fax: 209-579-7246
Mailing address:
  • Phone: 209-577-5557
  • Fax: 209-579-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN MERILLAT
Title or Position: PRESIDENT
Credential: MD
Phone: 209-577-5557