Provider Demographics
NPI:1871769000
Name:MED CENTER MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:MED CENTER MEDICAL CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-676-1450
Mailing Address - Street 1:6060 SUNRISE VISTA DR
Mailing Address - Street 2:STE 3050
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7053
Mailing Address - Country:US
Mailing Address - Phone:916-676-1450
Mailing Address - Fax:916-676-1447
Practice Address - Street 1:7988 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-7140
Practice Address - Country:US
Practice Address - Phone:916-961-7031
Practice Address - Fax:916-961-5218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MED CENTER MEDICAL CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-07
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10071363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA100712Medicare PIN