Basic Information
| Provider Information | |||||||||
| NPI: | 1700027661 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PRACTICE MEDICAL SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 801463 | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARITA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913801463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612950859 | ||||||||
| FaxNumber: | 6612950862 | ||||||||
| Practice Location | |||||||||
| Address1: | 274 W BADILLO ST | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263317369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2009 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | BETTS | ||||||||
| AuthorizedOfficialFirstName: | RANDOLPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6263317369 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A25707 | CA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | A25707 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | A25707 | 01 | CA | STATE LICENSE OF PRESIDENT | OTHER |