=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548341746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOC'S MEDICAL MART
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 11/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2625 ALTA ARDEN EXPRESSWAY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-979-1070
-----------------------------------------------------
Fax | 916-979-1030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19100 BIG BASIN WAY
-----------------------------------------------------
City | BOULDER CREEK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95006-8570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 831-338-6552
-----------------------------------------------------
Fax | 831-338-7777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | JOCELYN BISCHOFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 831-338-6552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 43832
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------