Provider Demographics
NPI:1366859449
Name:GOLDEN STATE PROVIDERS, A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:GOLDEN STATE PROVIDERS, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:SABA
Authorized Official - Middle Name:
Authorized Official - Last Name:HABIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-852-9100
Mailing Address - Street 1:2000 HEALTH PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4525
Mailing Address - Country:US
Mailing Address - Phone:615-373-7600
Mailing Address - Fax:866-346-1426
Practice Address - Street 1:865 PATRIOT DR STE 203
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3405
Practice Address - Country:US
Practice Address - Phone:805-370-4684
Practice Address - Fax:844-748-4623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty