Basic Information
| Provider Information | |||||||||
| NPI: | 1962750224 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL VALLEY CARDIOVASCULAR MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4978 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953524978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754575 | ||||||||
| FaxNumber: | 2095754598 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 E HAWKEYE AVE | ||||||||
| Address2: | |||||||||
| City: | TURLOCK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096688030 | ||||||||
| FaxNumber: | 2096688031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2012 | ||||||||
| LastUpdateDate: | 05/14/2019 | ||||||||
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| AuthorizedOfficialLastName: | NAZARI | ||||||||
| AuthorizedOfficialFirstName: | REZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2092505300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 40507 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1439840 | 05 | CA | MEDICAID | GO094A | 01 | CA | MEDICARE | OTHER |