Provider Demographics
NPI:1285361188
Name:LODI ADVANCED MEDICAL CENTER PC
Entity type:Organization
Organization Name:LODI ADVANCED MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-368-0619
Mailing Address - Street 1:1420 W KETTLEMAN LN STE K1
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-4559
Mailing Address - Country:US
Mailing Address - Phone:209-368-0619
Mailing Address - Fax:
Practice Address - Street 1:1420 W KETTLEMAN LN STE K1
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4559
Practice Address - Country:US
Practice Address - Phone:209-368-0619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-02
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty