Healthcare Provider Details

I. General information

NPI: 1861665309
Provider Name (Legal Business Name): COMMUNITY MEDICAL CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1721 E HAMMER LN
STOCKTON CA
95210-4116
US

IV. Provider business mailing address

PO BOX 779
STOCKTON CA
95201-0779
US

V. Phone/Fax

Practice location:
  • Phone: 209-751-5200
  • Fax: 209-751-5252
Mailing address:
  • Phone: 209-373-2828
  • Fax: 209-373-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. PAUL B WANDEL
Title or Position: CFO
Credential:
Phone: 209-373-2828