Healthcare Provider Details

I. General information

NPI: 1730112178
Provider Name (Legal Business Name): SAN JOAQUIN LASER AND SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 N CALIFORNIA ST STE 101A
STOCKTON CA
95204-6032
US

IV. Provider business mailing address

1805 N CALIFORNIA ST STE 101A
STOCKTON CA
95204-6032
US

V. Phone/Fax

Practice location:
  • Phone: 209-948-5515
  • Fax:
Mailing address:
  • Phone: 209-948-3241
  • Fax: 209-948-8009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number030000469
License Number StateCA

VIII. Authorized Official

Name: JANEE TAVARES
Title or Position: ADMINSTRATOR
Credential:
Phone: 209-948-3241