Organization
SAN JOAQUIN ORTHOTICS & PROSTHETICS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. MATTHEW SHANE EVANS CPO (BUSINESS OWNER/MANAGER)
(209) 932-0170
Entity
Organization
Contact information
Practice address
2211 N CALIFORNIA ST, STOCKTON, CA 95204-5503
(209) 932-0170
(209) 932-0172
Mailing address
2211 N CALIFORNIA ST, STOCKTON, CA 95204-5503
(209) 932-0170
(209) 932-0172
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
07-00072230
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
ZZZ07247Z
BLUE SHIELD
CA
Enumeration date
07/20/2006
Last updated
09/15/2015
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