Provider Demographics
NPI:1679626170
Name:ZACOALCO MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ZACOALCO MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:323-588-1383
Mailing Address - Street 1:5901 NILES ST
Mailing Address - Street 2:A
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-4780
Mailing Address - Country:US
Mailing Address - Phone:166-163-6723
Mailing Address - Fax:
Practice Address - Street 1:5901 NILES ST
Practice Address - Street 2:A
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93306-4780
Practice Address - Country:US
Practice Address - Phone:166-136-3723
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ZACOALCO MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-19
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75144207Q00000X
CA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080241Medicaid
CAGR0080241Medicaid