Healthcare Provider Details

I. General information

NPI: 1245309772
Provider Name (Legal Business Name): SANGER PEDIATRICS A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 11/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 JENSEN AVE
SANGER CA
93657-9777
US

IV. Provider business mailing address

2640 JENSEN AVE
SANGER CA
93657-9777
US

V. Phone/Fax

Practice location:
  • Phone: 559-876-1402
  • Fax: 559-876-9461
Mailing address:
  • Phone: 559-876-1402
  • Fax: 559-876-9461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number20A5923
License Number StateCA

VIII. Authorized Official

Name: DR. EMERSON B WALLS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 559-876-1402