Healthcare Provider Details

I. General information

NPI: 1548989692
Provider Name (Legal Business Name): SACRAMENTO STREET MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2022
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 DEL PASO BLVD
SACRAMENTO CA
95815-3101
US

IV. Provider business mailing address

2917 GRAYSON WAY
RANCHO CORDOVA CA
95670
US

V. Phone/Fax

Practice location:
  • Phone: 916-720-2237
  • Fax: 800-815-8510
Mailing address:
  • Phone: 916-800-4054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANTHONY MENACHO
Title or Position: EXECUTIVE DIRECTOR
Credential: PA-C
Phone: 909-730-5241