Basic Information
| Provider Information | |||||||||
| NPI: | 1154772705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTHCARE NETWORK | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FAMILY HEALTHCARE NETWORK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 305 E CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | VISALIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932916331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597374700 | ||||||||
| FaxNumber: | 5597341247 | ||||||||
| Practice Location | |||||||||
| Address1: | 12586 AVENUE 408 | ||||||||
| Address2: | |||||||||
| City: | OROSI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936479454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597412650 | ||||||||
| FaxNumber: | 5597412651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2016 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HYDASH | ||||||||
| AuthorizedOfficialFirstName: | KERRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5597374700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 52574 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2160790 | 01 | PK | OTHER |