Healthcare Provider Details

I. General information

NPI: 1760657092
Provider Name (Legal Business Name): YOSEMITE PATHOLOGY MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GREENLEY RD
SONORA CA
95370-5200
US

IV. Provider business mailing address

PO BOX 576768
MODESTO CA
95357-6768
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-1200
  • Fax: 209-577-6517
Mailing address:
  • Phone: 209-577-1200
  • Fax: 209-577-6517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberA24567
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberG66626
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License NumberG37943
License Number StateCA

VIII. Authorized Official

Name: ROBERT COLLETTI
Title or Position: CHIEF OPERATING OFFICER
Credential: MHA
Phone: 209-577-1200