Provider Demographics
NPI:1912412644
Name:ST. JUNIPERO CLINIC, INC.
Entity Type:Organization
Organization Name:ST. JUNIPERO CLINIC, INC.
Other - Org Name:ST. JUNIPERO CHILDREN'S CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:DARMAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-917-7737
Mailing Address - Street 1:333 ABBOTT ST STE C
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93901-4486
Mailing Address - Country:US
Mailing Address - Phone:831-288-8811
Mailing Address - Fax:831-998-7809
Practice Address - Street 1:333 ABBOTT ST STE C
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-4486
Practice Address - Country:US
Practice Address - Phone:831-288-8811
Practice Address - Fax:831-288-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-04
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA176005001Medicaid