Basic Information
| Provider Information | |||||||||
| NPI: | 1710542816 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL CENTERS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CMC, LODI VINE PEDIATRICS, SUITE 100 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7210 MURRAY DR | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952103339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093732800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2415 W VINE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093333135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2019 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| AuthorizedOfficialLastName: | NOGUERA | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093732831 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.