Provider Demographics
NPI:1447369566
Name:CENTRAL VALLEY ENT MEDICAL GROUP INC
Entity type:Organization
Organization Name:CENTRAL VALLEY ENT MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:KILLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-524-6681
Mailing Address - Street 1:1600 SUNRISE AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4679
Mailing Address - Country:US
Mailing Address - Phone:209-524-6681
Mailing Address - Fax:209-524-2962
Practice Address - Street 1:1600 SUNRISE AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4679
Practice Address - Country:US
Practice Address - Phone:209-524-6681
Practice Address - Fax:209-524-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ73209ZMedicaid