Provider Demographics
NPI:1881839959
Name:ENDOSCOPY CENTER OF LODI
Entity Type:Organization
Organization Name:ENDOSCOPY CENTER OF LODI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUEHNE
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:209-333-0905
Mailing Address - Street 1:840 S FAIRMONT AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5105
Mailing Address - Country:US
Mailing Address - Phone:209-371-8700
Mailing Address - Fax:209-369-1262
Practice Address - Street 1:840 S FAIRMONT AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5105
Practice Address - Country:US
Practice Address - Phone:209-371-8700
Practice Address - Fax:209-369-1262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
BQ951AOtherMEDICARE PTAN