Provider Demographics
NPI:1912347261
Name:1150 MAIN STREET INC
Entity Type:Organization
Organization Name:1150 MAIN STREET INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-728-0551
Mailing Address - Street 1:1150 MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3760
Mailing Address - Country:US
Mailing Address - Phone:831-728-0551
Mailing Address - Fax:831-728-3679
Practice Address - Street 1:1150 MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3760
Practice Address - Country:US
Practice Address - Phone:831-728-0551
Practice Address - Fax:831-728-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG56281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty