Basic Information
| Provider Information | |||||||||
| NPI: | 1083722516 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RIVER CITY MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SACRAMENTO FAMILY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15470 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958510470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9162284300 | ||||||||
| FaxNumber: | 9163824202 | ||||||||
| Practice Location | |||||||||
| Address1: | 2928 EASTERN AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958214210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169716702 | ||||||||
| FaxNumber: | 9169716709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 04/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | QUE | ||||||||
| AuthorizedOfficialFirstName: | KENDRICK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 9162284300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | RIVER CITY MEDICAL GROUP, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 320200 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0053756 | 05 | CA | MEDICAID | DA5949 | 01 | CA | RAILROAD MEDICARE | OTHER |