Healthcare Provider Details

I. General information

NPI: 1184798837
Provider Name (Legal Business Name): SHADELANDS ADVANCED ENDOSCOPY INSTITUTE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 02/10/2026
Certification Date: 02/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 N WIGET LN
WALNUT CREEK CA
94598-2408
US

IV. Provider business mailing address

498 N WIGET LN
WALNUT CREEK CA
94598-2408
US

V. Phone/Fax

Practice location:
  • Phone: 925-933-3600
  • Fax: 925-933-7900
Mailing address:
  • Phone: 925-948-8143
  • Fax: 925-215-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JENNIFER BOYD BALDOCK
Title or Position: OFFICER AND AUTHORIZED OFFICIAL
Credential:
Phone: 615-234-5954