Provider Demographics
NPI:1699823278
Name:SAN JOAQUIN VALLEY MEDICAL
Entity Type:Organization
Organization Name:SAN JOAQUIN VALLEY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPER
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:NYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-783-1181
Mailing Address - Street 1:536 N COURT ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4913
Mailing Address - Country:US
Mailing Address - Phone:559-732-4121
Mailing Address - Fax:559-732-1822
Practice Address - Street 1:536 N COURT ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291-4913
Practice Address - Country:US
Practice Address - Phone:559-732-4121
Practice Address - Fax:559-732-1822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A360321Medicaid
CA00A360321Medicare PIN