Provider Demographics
NPI:1760684526
Name:TEST-MED VACCINATION SERVICES MEDICAL CORP
Entity Type:Organization
Organization Name:TEST-MED VACCINATION SERVICES MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MARCUS
Authorized Official - Last Name:WILMOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-595-6734
Mailing Address - Street 1:PO BOX 1039
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92836-1039
Mailing Address - Country:US
Mailing Address - Phone:415-595-6734
Mailing Address - Fax:714-526-3110
Practice Address - Street 1:140 E SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1916
Practice Address - Country:US
Practice Address - Phone:415-595-6734
Practice Address - Fax:714-526-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86894261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAG932Medicare PIN
X97874Medicare UPIN
CAZZZ05540ZMedicare PIN
CAFLU017Medicare PIN