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General NPI Number Information
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NPI Number | 1194055749
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Entity Type | Organization
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Legal Business Name | N/A
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Dates
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Enumeration Date | 01/04/2010
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Last Update Date | 01/04/2010
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Provider Practice Location Address
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Address Line | 4051 LONE TREE WAY STE C
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City | ANTIOCH
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State | CA
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Zip | 94531-6204
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Country | US
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Telephone | 925-757-2900
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Fax |
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Provider Business Mailing Address
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Address Line | 1869 SAN ANDRES DR
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City | PITTSBURG
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State | CA
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Zip | 94565-7651
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Country | US
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Telephone | 925-458-5124
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Fax |
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Authorized Official
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Title or Position | PHLEBOTOMIST
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Name | MR. KEVIN ROLAND MARTIN
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Credential |
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Telephone | 925-458-5124
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 246RP1900X
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License Number State | CA
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