Basic Information
| Provider Information | |||||||||
| NPI: | 1841443686 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTERS FOR FAMILY MEDICINE - FHCLB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5626 OBERLIN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211705 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5977 E SPRING ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908083752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624213727 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8586252990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | G52798 | CA | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.