Provider Demographics
NPI:1710172721
Name:SAN JOAQUIN PRIME CARE MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:SAN JOAQUIN PRIME CARE MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-783-1181
Mailing Address - Street 1:330 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:CA
Mailing Address - Zip Code:93221-1838
Mailing Address - Country:US
Mailing Address - Phone:559-592-2134
Mailing Address - Fax:559-592-5017
Practice Address - Street 1:826 E MANNING AVE
Practice Address - Street 2:
Practice Address - City:REEDLEY
Practice Address - State:CA
Practice Address - Zip Code:93654-2232
Practice Address - Country:US
Practice Address - Phone:559-638-0400
Practice Address - Fax:559-638-0403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43893207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53947FMedicaid
CAGR0084784Medicaid
553947Medicare Oscar/Certification
CARHM53947FMedicaid