Provider Demographics
NPI:1912175456
Name:GK URGICARE,INC
Entity Type:Organization
Organization Name:GK URGICARE,INC
Other - Org Name:SJ MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDHYA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KOKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-665-1100
Mailing Address - Street 1:1695 S SAN JACINTO AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583
Mailing Address - Country:US
Mailing Address - Phone:951-665-1100
Mailing Address - Fax:951-665-1414
Practice Address - Street 1:1695 S SAN JACINTO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583
Practice Address - Country:US
Practice Address - Phone:951-665-1100
Practice Address - Fax:951-665-1414
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60821261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA60821OtherCALIF MEDICAL LICENSE