Basic Information
| Provider Information | |||||||||
| NPI: | 1538223375 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL CENTERS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952010779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093732833 | ||||||||
| FaxNumber: | 2093732878 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 E HAMMER LN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952104116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097515200 | ||||||||
| FaxNumber: | 2097515252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 05/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | KIRKPATRICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2093732833 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 1538223375 | 05 | CA | MEDICAID |