Provider Demographics
NPI:1346375136
Name:SPRUCE MULTISPECIATLY GROUP
Entity Type:Organization
Organization Name:SPRUCE MULTISPECIATLY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-226-0848
Mailing Address - Street 1:1275 E SPRUCE AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3345
Mailing Address - Country:US
Mailing Address - Phone:559-226-0848
Mailing Address - Fax:559-248-9585
Practice Address - Street 1:1275 E SPRUCE AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3345
Practice Address - Country:US
Practice Address - Phone:559-226-0848
Practice Address - Fax:559-248-9585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48359207R00000X
CAA43475207R00000X
CAA29316207R00000X
CAA79525207R00000X
CAG36222207RG0100X
CAG327842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0099780Medicaid
CA6421060001Medicare NSC
CAGR0099780Medicaid