Provider Demographics
NPI:1477796464
Name:INDEPENDENCE MEDICAL GROUP OF CENTRAL CALIFORNIA, INC.
Entity Type:Organization
Organization Name:INDEPENDENCE MEDICAL GROUP OF CENTRAL CALIFORNIA, INC.
Other - Org Name:INDEPENDENCE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HABERKERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-496-5638
Mailing Address - Street 1:100 WILLOW PLZ
Mailing Address - Street 2:SUITE 405
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6206
Mailing Address - Country:US
Mailing Address - Phone:559-802-1105
Mailing Address - Fax:559-750-4081
Practice Address - Street 1:100 WILLOW PLZ
Practice Address - Street 2:SUITE 405
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-6206
Practice Address - Country:US
Practice Address - Phone:559-802-1105
Practice Address - Fax:559-750-4081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization