Provider Demographics
NPI:1710228531
Name:COUNTY OF SAN JOAQUIN
Entity Type:Organization
Organization Name:COUNTY OF SAN JOAQUIN
Other - Org Name:SAN JOAQUIN COUNTY CLINICS PMC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FARHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FADOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-953-3700
Mailing Address - Street 1:10100 TRINITY PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:209-953-3700
Mailing Address - Fax:209-953-9195
Practice Address - Street 1:500 W HOSPITAL RD SUITE C
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-953-6400
Practice Address - Fax:209-468-7162
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF SAN JOAQUIN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-04
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000087261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA751128Medicare Oscar/Certification