Provider Demographics
NPI:1801074737
Name:STOCKTON NEUROLOGICAL MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:STOCKTON NEUROLOGICAL MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:CLIFT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-466-3551
Mailing Address - Street 1:2815 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3738
Mailing Address - Country:US
Mailing Address - Phone:209-466-3551
Mailing Address - Fax:209-465-7437
Practice Address - Street 1:2815 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3738
Practice Address - Country:US
Practice Address - Phone:209-466-3551
Practice Address - Fax:209-465-7437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG16430174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0067140Medicaid