Basic Information
| Provider Information | |||||||||
| NPI: | 1114965761 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EUREKA FAMILY PRACTICE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2675 HARRIS ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955034806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074438335 | ||||||||
| FaxNumber: | 7074437327 | ||||||||
| Practice Location | |||||||||
| Address1: | 2675 HARRIS ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955034806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074438335 | ||||||||
| FaxNumber: | 7074437327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | GOMES | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7074438335 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 9986915 | 05 | CA | MEDICAID |