=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275714917
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST NAZARENE MEDICAL CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2007
-----------------------------------------------------
Last Update Date | 01/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1100 N VENTURA RD SUITE 109
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93030-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-983-0547
-----------------------------------------------------
Fax | 805-983-0423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1100 NORTH VENTURA RD SUITE 109
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93030-3814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-983-0547
-----------------------------------------------------
Fax | 805-983-0423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SUZANNE L FUSSELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 805-983-0547
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | A055383
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------