Provider Demographics
NPI:1508936030
Name:COUNTY OF SACRAMENTO
Entity Type:Organization
Organization Name:COUNTY OF SACRAMENTO
Other - Org Name:CHEST CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:SENIOR ACCOUNT CLERK
Authorized Official - Prefix:MRS
Authorized Official - First Name:QUAITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:STUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-875-1416
Mailing Address - Street 1:7001-A EAST PARKWAY STE. 600
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2501
Mailing Address - Country:US
Mailing Address - Phone:916-875-5881
Mailing Address - Fax:916-875-6366
Practice Address - Street 1:4600 BROADWAY STE 1300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1527
Practice Address - Country:US
Practice Address - Phone:916-874-9823
Practice Address - Fax:916-874-9442
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SACRAMENTO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-09
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D0616630261QR0200X
261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEXE70041FMedicaid
CAZZR11521FMedicaid
CA05D0616630OtherCLIA NUMBER
CAZZZ91938ZMedicare ID - Type UnspecifiedMEDICARE CHEST CLINIC #