Provider Demographics
NPI:1124426705
Name:CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KARL
Authorized Official - Middle Name:P
Authorized Official - Last Name:VANGUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-443-2682
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2554 MERCED STREET
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721
Practice Address - Country:US
Practice Address - Phone:559-256-9660
Practice Address - Fax:559-489-0499
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL CALIFORNIA FACULTY MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-12
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies