Basic Information
| Provider Information | |||||||||
| NPI: | 1508974031 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SACRAMENTO FAMILY MEDICAL CLINIC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HMONG NEW LIFE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3441 MARYSVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958384512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165637230 | ||||||||
| FaxNumber: | 9165637229 | ||||||||
| Practice Location | |||||||||
| Address1: | 4241 FLORIN RD | ||||||||
| Address2: | SUITE 30 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958232535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164271227 | ||||||||
| FaxNumber: | 9164276325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 05/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | SIMON | ||||||||
| AuthorizedOfficialFirstName: | GILBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9165637230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 132640 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0053757 | 05 | CA | MEDICAID |