Provider Demographics
NPI:1679023980
Name:COUNTY OF SAN JOAQUIN
Entity Type:Organization
Organization Name:COUNTY OF SAN JOAQUIN
Other - Org Name:SAN JOAQUIN COUNTY CLINIC HAZELTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF AMBULATORY CARE SERVICE
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOMAOAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-468-6160
Mailing Address - Street 1:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-3120
Mailing Address - Country:US
Mailing Address - Phone:209-468-6937
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:1601 E HAZELTON AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-6229
Practice Address - Country:US
Practice Address - Phone:209-468-6937
Practice Address - Fax:209-468-7042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SAN JOAQUIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-11
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000087261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty