=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417801283
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE GENE JOE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2026
-----------------------------------------------------
Last Update Date | 02/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 SOQUEL AVE
-----------------------------------------------------
City | SANTA CRUZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95062-7805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-540-4141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9925 DEL SURF LN
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95757-2555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-528-0973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | 687350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------