Provider Demographics
NPI:1306819768
Name:OWENS PEAK MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:OWENS PEAK MEDICAL CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:FRANCINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DONGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-375-0100
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93556-0099
Mailing Address - Country:US
Mailing Address - Phone:760-375-0100
Mailing Address - Fax:760-375-0110
Practice Address - Street 1:1131 N CHINA LAKE BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3131
Practice Address - Country:US
Practice Address - Phone:760-375-0100
Practice Address - Fax:760-375-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A40869Medicaid
E89971Medicare UPIN
CA00A40869Medicaid