Healthcare Provider Details

I. General information

NPI: 1720422199
Provider Name (Legal Business Name): KAISER PERMANENTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 04/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7373 WEST LN
STOCKTON CA
95210-3377
US

IV. Provider business mailing address

7373 WEST LN
STOCKTON CA
95210-3377
US

V. Phone/Fax

Practice location:
  • Phone: 209-476-5445
  • Fax: 209-476-3528
Mailing address:
  • Phone: 209-476-5445
  • Fax: 209-476-3528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberLCS29352
License Number StateCA

VIII. Authorized Official

Name: MRS. ERIN SHURTLEFF
Title or Position: MANAGER
Credential:
Phone: 209-476-3904