=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437466521
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SJC MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2010
-----------------------------------------------------
Last Update Date | 09/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3609 VISTA WAY SUITE B
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92056-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-210-4725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23780 PORT ROYAL CT
-----------------------------------------------------
City | TEHACHAPI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93561-8585
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. MA. BELEN CLARK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 618-210-4725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A100202
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------