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NPI Code Detail

MEDICARE: SAN JOAQUIN LASER AND SURGERY CENTER

MEDICARE: SAN JOAQUIN LASER AND SURGERY CENTER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QA1903XAmbulatory Surgical Clinic/Center030000469CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ZZZ17148ZOTHERCAGROUP PTAN

General Provider Information

NPI Number : 1730112178
Entity Type Code : Organization
Provider Name (Legal Business Name) : SAN JOAQUIN LASER AND SURGERY CENTER
Provider Business Mailing Address
First Line : 1805 N CALIFORNIA ST STE 101A
Second Line :
City : STOCKTON
State : CA
Zip : 95204-6032
Country : US
Telephone Number : 209-948-3241
Fax Number : 209-948-8009
Provider Business Practice Location Address
First Line : 1805 N CALIFORNIA ST STE 101A
Second Line :
City : STOCKTON
State : CA
Zip : 95204-6032
Country : US
Telephone Number : 209-948-5515
Fax Number :
Authorized Official
Title or Position : ADMINSTRATOR
Name : JANEE TAVARES
Credential :
Telephone Number : 209-948-3241
Provider Enumeration Date : 07/09/2006
Last Update Date : 02/27/2025

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Directions to “SAN JOAQUIN LASER AND SURGERY CENTER ” Practice Location

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