Provider Demographics
NPI:1275011546
Name:MISSION AVENUE MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:MISSION AVENUE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:SLECHTA
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:916-601-4513
Mailing Address - Street 1:3625 MISSION AVE STE D
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2954
Mailing Address - Country:US
Mailing Address - Phone:916-486-1906
Mailing Address - Fax:916-486-9566
Practice Address - Street 1:3625 MISSION AVE STE D
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2954
Practice Address - Country:US
Practice Address - Phone:916-486-1906
Practice Address - Fax:916-486-9566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care