Basic Information
| Provider Information | |||||||||
| NPI: | 1346646072 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOGEN, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SYNERGY HEALTH CENTER & URGENT CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3128 SANTA RITA RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945668300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253504742 | ||||||||
| FaxNumber: | 8005070879 | ||||||||
| Practice Location | |||||||||
| Address1: | 3128 SANTA RITA RD | ||||||||
| Address2: | |||||||||
| City: | PLEASANTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945668300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9253504742 | ||||||||
| FaxNumber: | 8005070879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2014 | ||||||||
| LastUpdateDate: | 01/26/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 9253504742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 551003 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.