Provider Demographics
NPI:1730277344
Name:NCSRA MEDICAL CORPORATION
Entity type:Organization
Organization Name:NCSRA MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAUFUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-389-7130
Mailing Address - Street 1:2 SCRIPPS DR STE 310
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-6207
Mailing Address - Country:US
Mailing Address - Phone:916-389-7130
Mailing Address - Fax:916-389-7140
Practice Address - Street 1:2801 K ST
Practice Address - Street 2:SUITE 410
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5119
Practice Address - Country:US
Practice Address - Phone:916-389-7100
Practice Address - Fax:916-389-7140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherFEDRAL TAX ID #