Provider Demographics
NPI:1417923400
Name:SPRINGBOK MEDICAL GROUP INC
Entity Type:Organization
Organization Name:SPRINGBOK MEDICAL GROUP INC
Other - Org Name:THOUSAND OAKS URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:MYFANWY
Authorized Official - Last Name:HENRIOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-495-6866
Mailing Address - Street 1:620 E JANSS RD
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-5113
Mailing Address - Country:US
Mailing Address - Phone:805-495-6866
Mailing Address - Fax:805-495-8085
Practice Address - Street 1:620 E JANSS RD
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5113
Practice Address - Country:US
Practice Address - Phone:805-495-6866
Practice Address - Fax:805-495-8085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114850001Medicare NSC
CAGB146AMedicare PIN