Basic Information
| Provider Information | |||||||||
| NPI: | 1457552960 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRACTICE HEALTH AND WELLNESS MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 STANDIFORD AVE | ||||||||
| Address2: | D3 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953506529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754990 | ||||||||
| FaxNumber: | 2095754996 | ||||||||
| Practice Location | |||||||||
| Address1: | 2020 STANDIFORD AVE | ||||||||
| Address2: | D3 | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953506529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095754990 | ||||||||
| FaxNumber: | 2095754996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2007 | ||||||||
| LastUpdateDate: | 11/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | STAFF MD | ||||||||
| AuthorizedOfficialTelephone: | 2095754990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G77641 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.