Provider Demographics
NPI:1669679189
Name:THE GOOD NEIGHBOR WALK IN CLINIC, INC
Entity Type:Organization
Organization Name:THE GOOD NEIGHBOR WALK IN CLINIC, INC
Other - Org Name:GOOD NEIGHBOR MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:AW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-221-9088
Mailing Address - Street 1:4844 N 1ST ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-0529
Mailing Address - Country:US
Mailing Address - Phone:559-221-9088
Mailing Address - Fax:559-221-9087
Practice Address - Street 1:4844 N 1ST ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-0529
Practice Address - Country:US
Practice Address - Phone:559-221-9088
Practice Address - Fax:559-221-9087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53206171100000X, 207RG0300X
CA00A532060261QP2300X
CARN505630-NP8370261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP0083700Medicaid
CA00A532060Medicaid
CA00A532060Medicaid
CAZZZ07014ZMedicare PIN
CAS49922Medicare UPIN
CAZZZ07012ZMedicare PIN
CANP0083700Medicaid