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General NPI Number Information
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NPI Number | 1730112178
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Entity Type | Organization
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Legal Business Name | SAN JOAQUIN LASER AND SURGERY CENTER
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Dates
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Enumeration Date | 07/09/2006
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Last Update Date | 02/27/2025
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Provider Practice Location Address
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Address Line | 1805 N CALIFORNIA ST STE 101A
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City | STOCKTON
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State | CA
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Zip | 95204-6032
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Country | US
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Telephone | 209-948-5515
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Fax |
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Provider Business Mailing Address
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Address Line | 1805 N CALIFORNIA ST STE 101A
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City | STOCKTON
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State | CA
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Zip | 95204-6032
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Country | US
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Telephone | 209-948-3241
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Fax | 209-948-8009
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Authorized Official
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Title or Position | ADMINSTRATOR
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Name | JANEE TAVARES
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Credential |
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Telephone | 209-948-3241
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 030000469
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License Number State | CA
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