Basic Information
| Provider Information | |||||||||
| NPI: | 1679023980 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SAN JOAQUIN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAN JOAQUIN COUNTY CLINIC HAZELTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1020 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952013120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686937 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 E HAZELTON AVE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952056229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686937 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2016 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOMAOAS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF AMBULATORY CARE SERVICE | ||||||||
| AuthorizedOfficialTelephone: | 2094686160 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF SAN JOAQUIN | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 030000087 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.