Basic Information
Provider Information | |||||||||
NPI: | 1932749108 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VANGUARD MEDICAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 565 KERN ST | ||||||||
Address2: |   | ||||||||
City: | SHAFTER | ||||||||
State: | CA | ||||||||
PostalCode: | 932632133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6614591000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 500 OLD RIVER RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | BAKERSFIELD | ||||||||
State: | CA | ||||||||
PostalCode: | 933119515 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6614591010 | ||||||||
FaxNumber: | 8552002829 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/15/2020 | ||||||||
LastUpdateDate: | 01/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SUNNER | ||||||||
AuthorizedOfficialFirstName: | NOVIRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 6615995310 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.