1164754347 NPI number — FAMILY PRACTICE HEALTH AND WELLNESS, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164754347 NPI number — FAMILY PRACTICE HEALTH AND WELLNESS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY PRACTICE HEALTH AND WELLNESS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164754347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2980 N BEVERLY GLEN CIR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90077-1728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-474-9809
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2020 STANDIFORD AVE
Provider Second Line Business Practice Location Address:
BLD D SUITE D1
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95350-6529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-575-4990
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTOPHER
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
209-575-4990

Provider Taxonomy Codes

  • Taxonomy code: 332900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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