Provider Demographics
NPI:1710009659
Name:COMMUNITY MEDICAL CENTERS, INC.
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL CENTERS, INC.
Other - Org Name:WOODBRIDGE MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIRKPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-373-2833
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0779
Mailing Address - Country:US
Mailing Address - Phone:209-370-1700
Mailing Address - Fax:209-370-1737
Practice Address - Street 1:2401 W TURNER RD
Practice Address - Street 2:SUITE 450
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-2182
Practice Address - Country:US
Practice Address - Phone:209-370-1700
Practice Address - Fax:209-370-1737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70460FOtherSOFP