Provider Demographics
NPI:1639183486
Name:SAN JOAQUIN LASER SURGERY CENTER
Entity Type:Organization
Organization Name:SAN JOAQUIN LASER SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:EDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-948-5515
Mailing Address - Street 1:1805 N CALIFORNIA ST
Mailing Address - Street 2:SUITE 101 A
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6037
Mailing Address - Country:US
Mailing Address - Phone:209-948-3241
Mailing Address - Fax:209-948-9321
Practice Address - Street 1:1805 N CALIFORNIA ST
Practice Address - Street 2:SUITE 101 A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6037
Practice Address - Country:US
Practice Address - Phone:209-948-3241
Practice Address - Fax:209-948-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30000469261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ17148ZMedicare ID - Type Unspecified