Provider Demographics
NPI:1396020947
Name:ADVANCED SLEEP AND GASTROENTEROLOGY LABORATORIES,INC.
Entity Type:Organization
Organization Name:ADVANCED SLEEP AND GASTROENTEROLOGY LABORATORIES,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-751-7165
Mailing Address - Street 1:262 BURGENLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-0343
Mailing Address - Country:US
Mailing Address - Phone:209-751-7165
Mailing Address - Fax:209-579-2354
Practice Address - Street 1:4206 TECHNOLOGY DR STE 2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8769
Practice Address - Country:US
Practice Address - Phone:209-492-0735
Practice Address - Fax:209-579-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty