Healthcare Provider Details

I. General information

NPI: 1912412644
Provider Name (Legal Business Name): ST. JUNIPERO CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 ABBOTT ST STE C
SALINAS CA
93901-4486
US

IV. Provider business mailing address

333 ABBOTT ST STE C
SALINAS CA
93901-4486
US

V. Phone/Fax

Practice location:
  • Phone: 831-288-8811
  • Fax: 831-288-8866
Mailing address:
  • Phone: 831-288-8811
  • Fax: 831-998-7809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA85492
License Number StateCA

VIII. Authorized Official

Name: STEVE DARMAWAN
Title or Position: PRESIDENT
Credential: MD
Phone: 831-917-7737