Provider Demographics
NPI:1982035069
Name:SAN BLAS MEDICAL CLINIC
Entity Type:Organization
Organization Name:SAN BLAS MEDICAL CLINIC
Other - Org Name:CLINICA MEDICA SAN BLAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:FRAUSTO
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:714-220-2223
Mailing Address - Street 1:7777 KATELLA AVENUE
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680
Mailing Address - Country:US
Mailing Address - Phone:714-220-2223
Mailing Address - Fax:714-220-2249
Practice Address - Street 1:7777 KATELLA AVENUE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680
Practice Address - Country:US
Practice Address - Phone:714-220-2223
Practice Address - Fax:714-220-2249
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN BLAS MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-27
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-79043208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty