Basic Information
| Provider Information | |||||||||
| NPI: | 1457621922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL CENTERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7210 MURRAY DR | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952103339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093732800 | ||||||||
| FaxNumber: | 2093732879 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 COTTAGE AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953364935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096245800 | ||||||||
| FaxNumber: | 2096245801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2011 | ||||||||
| LastUpdateDate: | 12/30/2011 | ||||||||
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| AuthorizedOfficialLastName: | BAGALAYOS | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2093732838 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 550000238 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1710211214 | 05 | CA | MEDICAID |