Basic Information
| Provider Information | |||||||||
| NPI: | 1871769000 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MED CENTER MEDICAL CLINIC, INC | ||||||||
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| OtherOrganizationName: | DR CHAMPLIN'S ANNEX | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6060 SUNRISE VISTA DR | ||||||||
| Address2: | STE 3050 | ||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956107053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166761450 | ||||||||
| FaxNumber: | 9166761447 | ||||||||
| Practice Location | |||||||||
| Address1: | 7988 CALIFORNIA AVE | ||||||||
| Address2: | |||||||||
| City: | FAIR OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956287140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169617031 | ||||||||
| FaxNumber: | 9169615218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2008 | ||||||||
| LastUpdateDate: | 01/22/2009 | ||||||||
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| AuthorizedOfficialLastName: | ADGE | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9166761450 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MED CENTER MEDICAL CLINIC, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10071 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.