Basic Information
| Provider Information | |||||||||
| NPI: | 1750865804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | C.O.R.E. MEDICAL CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 CAPITOL AVE | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164424985 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3990 INDUSTRIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956913430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164424985 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2018 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | STENSON | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS SERVICES DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9164424985 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | C.O.R.E. MEDICAL CLINIC, INC. | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
No ID Information.