Provider Demographics
NPI:1003055476
Name:SANCLAIR CORPORATION
Entity Type:Organization
Organization Name:SANCLAIR CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BRACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-673-8252
Mailing Address - Street 1:69115 RAMON RD
Mailing Address - Street 2:STE F1512
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-9114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69115 RAMON RD
Practice Address - Street 2:STE F1512
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-9114
Practice Address - Country:US
Practice Address - Phone:760-673-8252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60080207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABM079AMedicare PIN