Basic Information
| Provider Information | |||||||||
| NPI: | 1912472531 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONCENTRA PRIMARY CARE OF CALIFORNIA, A MEDICAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CONCENTRA MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5080 SPECTRUM DR STE 1200W | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014624 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5080 SPECTRUM DR STE 1200W | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750014624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9723648000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2018 | ||||||||
| LastUpdateDate: | 01/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 9723648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QH0100X | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.