Healthcare Provider Details

I. General information

NPI: 1982958351
Provider Name (Legal Business Name): SACRAMENTO PEDIATRIC GASTROENTEROLOGY,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5767 GREENBACK LN SUITE 200
SACRAMENTO CA
95841-2013
US

IV. Provider business mailing address

5767 GREENBACK LN SUITE 200
SACRAMENTO CA
95841-2013
US

V. Phone/Fax

Practice location:
  • Phone: 916-332-1244
  • Fax: 916-760-4147
Mailing address:
  • Phone: 916-332-1244
  • Fax: 916-760-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA71235
License Number StateCA

VIII. Authorized Official

Name: YINKA KARI DAVIES
Title or Position: PEDIATRIC GASTROENTEROLOGIST
Credential: MD
Phone: 916-332-1244