Healthcare Provider Details

I. General information

NPI: 1245620954
Provider Name (Legal Business Name): SHADELANDS ENDOVASCULAR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2015
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N WIGET LN STE B
WALNUT CREEK CA
94598-2408
US

IV. Provider business mailing address

460 N WIGET LN STE B
WALNUT CREEK CA
94598-2408
US

V. Phone/Fax

Practice location:
  • Phone: 925-627-3495
  • Fax: 925-891-4322
Mailing address:
  • Phone: 925-627-3495
  • Fax: 925-891-4322

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: INEZ WONDEH
Title or Position: COO
Credential:
Phone: 925-378-4500