Provider Demographics
NPI:1669548657
Name:THE PERMANENTE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:THE PERMANENTE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-625-6266
Mailing Address - Street 1:11811 VENICE BLVD APT 211
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3933
Mailing Address - Country:US
Mailing Address - Phone:408-230-3222
Mailing Address - Fax:
Practice Address - Street 1:710 LAWRENCE EXPY
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-5173
Practice Address - Country:US
Practice Address - Phone:408-851-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88751302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization