=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700042611
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRAMENTO VAN CONVERSIONS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2008
-----------------------------------------------------
Last Update Date | 07/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5821 FLORIN PERKINS RD
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95828-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-381-8267
-----------------------------------------------------
Fax | 916-381-1946
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5821 FLORIN PERKINS RD
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95828-1032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-381-8267
-----------------------------------------------------
Fax | 916-381-1946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. FIDEL S. BARAJAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-381-8267
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 11380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------