Basic Information
| Provider Information | |||||||||
| NPI: | 1063684405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OMNI FAMILY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NATIONAL HEALTH SERVICES, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 CALIFORNIA AVE | ||||||||
| Address2: | 400B | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933097081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614591900 | ||||||||
| FaxNumber: | 6614591944 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 MILL STREET | ||||||||
| Address2: | |||||||||
| City: | TEHACHAPI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935612523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6618229054 | ||||||||
| FaxNumber: | 6618229082 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2008 | ||||||||
| LastUpdateDate: | 07/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | CASTILLON | ||||||||
| AuthorizedOfficialFirstName: | FRANCISCO | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6616307050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | CLP 320413 | CA | N | Laboratories | Clinical Medical Laboratory | 291U00000X | CLP320413 | CA | N | Laboratories | Clinical Medical Laboratory | 261QF0400X | 555000030 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | HAP71079F | 01 | CA | MEDI-CAL | OTHER |