Provider Demographics
NPI:1457603664
Name:SAN ANDREAS SLEEP DISORDERS MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:SAN ANDREAS SLEEP DISORDERS MEDICAL GROUP, INC
Other - Org Name:SAN ANDREAS SLEEP CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JOYNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-754-5374
Mailing Address - Street 1:704 MOUNTAIN RANCH RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-9707
Mailing Address - Country:US
Mailing Address - Phone:209-754-5374
Mailing Address - Fax:209-754-5376
Practice Address - Street 1:704 MOUNTAIN RANCH RD
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9707
Practice Address - Country:US
Practice Address - Phone:209-754-5374
Practice Address - Fax:209-754-5376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45770207RP1001X, 207RS0012X
CAA101134207RS0012X
CAA56143207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty