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General NPI Number Information
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NPI Number | 1649290107
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Entity Type | Organization
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Legal Business Name | SAN JOAQUIN ORTHOTICS & PROSTHETICS
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 09/15/2015
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Provider Practice Location Address
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Address Line | 2211 N CALIFORNIA ST
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City | STOCKTON
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State | CA
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Zip | 95204-5503
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Country | US
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Telephone | 209-932-0170
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Fax | 209-932-0172
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Provider Business Mailing Address
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Address Line | 2211 N CALIFORNIA ST
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City | STOCKTON
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State | CA
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Zip | 95204-5503
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Country | US
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Telephone | 209-932-0170
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Fax | 209-932-0172
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Authorized Official
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Title or Position | BUSINESS OWNER/MANAGER
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Name | MR. MATTHEW SHANE EVANS
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Credential | CPO
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Telephone | 209-932-0170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 07-00072230
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License Number State | CA
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