Provider Demographics
NPI:1164186896
Name:COUNTY OF SAN JOAQUIN
Entity Type:Organization
Organization Name:COUNTY OF SAN JOAQUIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:FARHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FADOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-468-5623
Mailing Address - Street 1:10100 TRINITY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-7239
Mailing Address - Country:US
Mailing Address - Phone:209-468-5623
Mailing Address - Fax:209-468-6114
Practice Address - Street 1:500 W HOSPITAL RD STE A
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6937
Practice Address - Fax:209-468-6114
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SAN JOAQUIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA030000087OtherNA