Provider Demographics
NPI:1649290107
Name:SAN JOAQUIN ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:SAN JOAQUIN ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:209-932-0170
Mailing Address - Street 1:2211 N CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-5503
Mailing Address - Country:US
Mailing Address - Phone:209-932-0170
Mailing Address - Fax:209-932-0172
Practice Address - Street 1:2211 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-5503
Practice Address - Country:US
Practice Address - Phone:209-932-0170
Practice Address - Fax:209-932-0172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07-00072230335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ07247ZOtherBLUE SHIELD
CA4879760001Medicare ID - Type Unspecified