Provider Demographics
NPI:1508946476
Name:MEDESTATE INC.
Entity Type:Organization
Organization Name:MEDESTATE INC.
Other - Org Name:EXCELCARE IMMEDIATE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-645-7229
Mailing Address - Street 1:3431 BROADWAY ST
Mailing Address - Street 2:SUITE A-8
Mailing Address - City:AMERICAN CANYON
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1228
Mailing Address - Country:US
Mailing Address - Phone:707-645-7229
Mailing Address - Fax:707-645-7431
Practice Address - Street 1:3431 BROADWAY ST
Practice Address - Street 2:SUITE A-8
Practice Address - City:AMERICAN CANYON
Practice Address - State:CA
Practice Address - Zip Code:94503-1228
Practice Address - Country:US
Practice Address - Phone:707-645-7229
Practice Address - Fax:707-645-7431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A0627550261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care