Provider Demographics
NPI:1205933496
Name:SANTA CRUZ PERSONAL PHYSICIANS INC
Entity type:Organization
Organization Name:SANTA CRUZ PERSONAL PHYSICIANS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:LAURENCIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-421-9535
Mailing Address - Street 1:634 FREDERICK ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062
Mailing Address - Country:US
Mailing Address - Phone:831-421-9535
Mailing Address - Fax:831-421-9290
Practice Address - Street 1:634 FREDERICK ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062
Practice Address - Country:US
Practice Address - Phone:831-421-9535
Practice Address - Fax:831-421-9290
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E78393Medicare UPIN
ZZZ01579ZMedicare ID - Type Unspecified