Provider Demographics
NPI:1992988513
Name:SA HAGGERTY, INC., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SA HAGGERTY, INC., A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HAGGERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-365-7640
Mailing Address - Street 1:1416 TOWSE DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95776-6715
Mailing Address - Country:US
Mailing Address - Phone:707-365-7640
Mailing Address - Fax:815-361-9113
Practice Address - Street 1:5290 ELVAS AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-2332
Practice Address - Country:US
Practice Address - Phone:916-739-1507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98050208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty