=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386143147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALLEY SUNSHINE MEDICAL ASSOCIATES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2018
-----------------------------------------------------
Last Update Date | 09/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 751 W LEGION RD
-----------------------------------------------------
City | BRAWLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92227-7732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-351-3444
-----------------------------------------------------
Fax | 760-351-3450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7096
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95267-0096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-956-7725
-----------------------------------------------------
Fax | 209-956-7733
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RAMAIAH INDUDHARA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-450-6954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------