Provider Demographics
NPI:1629022561
Name:MC IBANEZ MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MC IBANEZ MEDICAL CORPORATION
Other - Org Name:PRIMELIFE MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CAESAR
Authorized Official - Middle Name:LOCSIN
Authorized Official - Last Name:IBANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-681-5000
Mailing Address - Street 1:8100 TIMBERLAKE WAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5409
Mailing Address - Country:US
Mailing Address - Phone:916-681-5000
Mailing Address - Fax:916-681-5887
Practice Address - Street 1:8100 TIMBERLAKE WAY
Practice Address - Street 2:SUITE C
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5409
Practice Address - Country:US
Practice Address - Phone:916-681-5000
Practice Address - Fax:916-681-5887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A645050Medicaid
CAH06855Medicare UPIN
CA00A645050Medicaid