Provider Demographics
NPI:1376767665
Name:UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER
Entity Type:Organization
Organization Name:UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC SOCIAL WORKER
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:FONG
Authorized Official - Suffix:
Authorized Official - Credentials:ACSW 16761
Authorized Official - Phone:916-734-1665
Mailing Address - Street 1:3304 MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618
Mailing Address - Country:US
Mailing Address - Phone:530-758-5385
Mailing Address - Fax:916-734-0561
Practice Address - Street 1:2521 STOCKTON BLVD STE 3110
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2207
Practice Address - Country:US
Practice Address - Phone:916-734-1665
Practice Address - Fax:916-734-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW 16761OtherCLINICAL SOCIAL WORKER