Basic Information
| Provider Information | |||||||||
| NPI: | 1881685964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEDICAL CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WOODBRIDGE MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 779 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952010779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093732800 | ||||||||
| FaxNumber: | 2093732878 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 W TURNER RD | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952422182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093701700 | ||||||||
| FaxNumber: | 2093701737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/14/2010 | ||||||||
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| AuthorizedOfficialLastName: | KIRKPATRICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2093732833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 030000424 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FHC70460F | 05 | CA | MEDICAID |