Healthcare Provider Details

I. General information

NPI: 1376554824
Provider Name (Legal Business Name): ALLERGY IMMUNOLOGY AND ASTHMA MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4628 GEORGETOWN PL
STOCKTON CA
95207-6204
US

IV. Provider business mailing address

4628 GEORGETOWN PL
STOCKTON CA
95207-6204
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-6177
  • Fax: 209-478-6219
Mailing address:
  • Phone: 209-478-6177
  • Fax: 209-478-6219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateCA

VIII. Authorized Official

Name: PATTI A GRIFFIN
Title or Position: BILLING MANAGER
Credential:
Phone: 209-478-6177