Provider Demographics
NPI:1801887716
Name:COMMUNITY MEDICAL CENTERS
Entity type:Organization
Organization Name:COMMUNITY MEDICAL CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:B
Authorized Official - Last Name:WANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-944-4710
Mailing Address - Street 1:PO BOX 779
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-0779
Mailing Address - Country:US
Mailing Address - Phone:209-944-4710
Mailing Address - Fax:209-944-4796
Practice Address - Street 1:265 W SAINT CHARLES ST
Practice Address - Street 2:# 3
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9618
Practice Address - Country:US
Practice Address - Phone:209-755-1400
Practice Address - Fax:209-755-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70461FMedicaid
CA051831Medicare ID - Type Unspecified