Organization
SAN JOAQUIN VALLEY NEONATAL MEDICAL ASSOCATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. GINA WALLACE (BILLING AGENT)
(209) 571-8330
Entity
Organization
Contact information
Practice address
500 W HOSPITAL RD, FRENCH CAMP, CA 95231-9693
(209) 571-8330
(209) 491-7184
Mailing address
1524 MCHENRY AVE, SUITE 150, MODESTO, CA 95350-4500
(209) 571-8330
(209) 491-7184
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
50579
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
50579
BLUE SHIELD
CA
05
—
GR0071220
—
CA
Enumeration date
08/01/2007
Last updated
08/01/2007
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