Bautista Rural Medical Clinics, Inc.
Organization Active NPI Internal Medicine Physician · Sanger, CA
NPI 1689746208 · NPPES record last updated Oct 5, 2010
Key facts
- NPI
- 1689746208
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Internal Medicine Physician 207R00000X
- License
- A432930 (CO)
- Legal business name
- BAUTISTA RURAL MEDICAL CLINICS, INC.
- Practice address
- 2570 Jensen Ave
Suite 106
Sanger, CA 93657-2269 - Phone
- (559) 875-3428
- Fax
- (559) 875-3434
- NPI assigned
- Nov 15, 2006
- Organization subpart
- No
Authorized official
- Name
- Mrs. Blanca E Escobar
- Title
- Billing Director
- Phone
- (559) 875-3428
Owners & managing parties with NPI records 1
-
Jose Luis Bautista, M.D.
Practitioners 2
-
Jose Luis Bautista, M.D.
-
Jose Luis Flores, MD
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 05D0885707 | Bautista Rural Medical Clinic Inc | Certificate of waiver | Apr 28, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
Rural health clinic certification: CCN 553933
- Legal name
- BAUTISTA RURAL MEDICAL CLINICS, INC.
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Nov 8, 2000
- Last certification
- Dec 4, 2017
- Ownership / control type
- 2A
- Organization structure
- Corporation · Proprietary
- Enrollment address
- 2570 Jensen Avenue
Suite 106
Sanger, CA 93657-2269
All disclosed owners & managing parties 1
| Name | Role | Since | Share |
|---|---|---|---|
| Jose L Bautista |
5% Or Greater Direct Ownership Interest |
Nov 8, 2000 | |
| Corporate Director |
Nov 8, 2000 | 100% | |
| W-2 Managing Employee |
Nov 8, 2000 | 95% | |
| Operational/Managerial Control |
Nov 8, 2000 | 95% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20030515000050 | CA | Part a Provider - Rural Health Clinic | 0840100301 | Practice locations: Sanger, CA |
National Provider Directory
Locations
2570 Jensen Ave
Ste 106
Sanger, CA 93657
Phone (559) 875-3428
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician |
207R00000X | A432930 | CO | Yes |
| Physician Assistant |
363A00000X | PA 13143 | CA | |
| Physician Assistant |
363A00000X | PA21266 | CA |
Addresses
Primary practice location
2570 Jensen Ave
Suite 106
Sanger, CA 93657-2269
Mailing address
2570 Jensen Ave
Suite 106
Sanger, CA 93657-2269
Phone (559) 875-3428
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| RHM53933F | Medicaid | CA | |
| BZ069A | Other | CA | MEDICARE PTAN / PALMETTO |
Other providers in Sanger, CA
- Alexis Marie Ayala
- Serena Marie Ayala
- Barr Pharmacy Inc
- Barr Pharmacy Inc
- Bautista Health Care, Inc.
- Jose Luis Bautista
- Lacie Danielle Beasley
- Alejandra Jaimes Bedolla
- John Bejeckian
- Felicia Betancourt
All providers in Sanger, CA · Internal Medicine Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 5, 2010. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.