Provider Demographics
NPI:1699195115
Name:DAMERON HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:DAMERON HOSPITAL ASSOCIATION
Other - Org Name:AMBULATORY CARE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:P
Authorized Official - Last Name:AUERBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-461-3100
Mailing Address - Street 1:525 W. ACACIA STREET
Mailing Address - Street 2:ATTN: FINANCE DEPARTMENT
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95203-2484
Mailing Address - Country:US
Mailing Address - Phone:209-461-3148
Mailing Address - Fax:209-461-3130
Practice Address - Street 1:530 W ACACIA ST
Practice Address - Street 2:SUITE 1
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2454
Practice Address - Country:US
Practice Address - Phone:209-944-5410
Practice Address - Fax:209-944-5477
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAMERON HOSPITAL ASSOCIATIONI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-04-23
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
05-0122OtherMEDICARE ID-TYPE UNSPECIFIED