=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003055476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANCLAIR CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2009
-----------------------------------------------------
Last Update Date | 05/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 69115 RAMON RD STE F1512
-----------------------------------------------------
City | CATHEDRAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92234-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-673-8252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 69115 RAMON RD STE F1512
-----------------------------------------------------
City | CATHEDRAL CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92234-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JEFFREY C BRACKETT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 760-673-8252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | A60080
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------