Provider Demographics
NPI:1043212376
Name:EAR NOSE AND THROAT MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:EAR NOSE AND THROAT MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-434-1836
Mailing Address - Street 1:1050 LAS TABLAS RD
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-9729
Mailing Address - Country:US
Mailing Address - Phone:805-434-1836
Mailing Address - Fax:805-434-1590
Practice Address - Street 1:1050 LAS TABLAS RD
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-9729
Practice Address - Country:US
Practice Address - Phone:805-434-1836
Practice Address - Fax:805-434-1590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19580207YX0602X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW3574Medicare PIN
CAA40693Medicare UPIN