Healthcare Provider Details

I. General information

NPI: 1932757150
Provider Name (Legal Business Name): JAMES BURGESS ANGEL OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 W. EATON AVE.
TRACY CA
95376
US

IV. Provider business mailing address

477 W 22ND ST
TRACY CA
95376-2544
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-4062
  • Fax: 209-839-8316
Mailing address:
  • Phone: 925-667-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number18-0917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: