Healthcare Provider Details

I. General information

NPI: 1396020947
Provider Name (Legal Business Name): ADVANCED SLEEP AND GASTROENTEROLOGY LABORATORIES,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4206 TECHNOLOGY DR STE 2
MODESTO CA
95356-8769
US

IV. Provider business mailing address

262 BURGENLAND AVE
TURLOCK CA
95382-0343
US

V. Phone/Fax

Practice location:
  • Phone: 209-492-0735
  • Fax: 209-579-2354
Mailing address:
  • Phone: 209-751-7165
  • Fax: 209-579-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN SAM DAVIDSON
Title or Position: CEO
Credential: MD
Phone: 209-751-7165