Provider Demographics
NPI:1679673719
Name:SAN JOAQUIN WELLNESS & MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SAN JOAQUIN WELLNESS & MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:661-324-4431
Mailing Address - Street 1:1201 24TH ST
Mailing Address - Street 2:B-200
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2310
Mailing Address - Country:US
Mailing Address - Phone:661-324-4431
Mailing Address - Fax:661-324-5616
Practice Address - Street 1:1201 24TH ST
Practice Address - Street 2:B-200
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2310
Practice Address - Country:US
Practice Address - Phone:661-324-4431
Practice Address - Fax:661-324-5616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0143200111N00000X
CAA89666208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31754ZMedicare PIN