Healthcare Provider Details

I. General information

NPI: 1710172721
Provider Name (Legal Business Name): SAN JOAQUIN PRIME CARE MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 E MANNING AVE
REEDLEY CA
93654-2232
US

IV. Provider business mailing address

330 E PINE ST
EXETER CA
93221-1838
US

V. Phone/Fax

Practice location:
  • Phone: 559-638-0400
  • Fax: 559-638-0403
Mailing address:
  • Phone: 559-592-2134
  • Fax: 559-592-5017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA43893
License Number StateCA

VIII. Authorized Official

Name: KIMBERLY BURGINS
Title or Position: BILLING SUPERVISOR
Credential:
Phone: 559-783-1181