Healthcare Provider Details

I. General information

NPI: 1487805370
Provider Name (Legal Business Name): EXPRESS METABOLICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2008
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 GOODWIN DR
RIPON CA
95366-9446
US

IV. Provider business mailing address

1112 N MAIN ST PMB 114
MANTECA CA
95336-3208
US

V. Phone/Fax

Practice location:
  • Phone: 209-608-8672
  • Fax:
Mailing address:
  • Phone: 209-608-8672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberPA16158
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: REBEKAH M LEE
Title or Position: OWNER/CLINIC MANAGER
Credential: PA-C
Phone: 209698088672