Basic Information
| Provider Information | |||||||||
| NPI: | 1851510986 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OMNI FAMILY HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NATIONAL HEALTH SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 CALIFORNIA AVE | ||||||||
| Address2: | 400B | ||||||||
| City: | BAKERSFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 933097081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6614591900 | ||||||||
| FaxNumber: | 6614591974 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 S CENTRAL VALLEY HWY | ||||||||
| Address2: | |||||||||
| City: | SHAFTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932632790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617469194 | ||||||||
| FaxNumber: | 6617469197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 05/05/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASTILLON | ||||||||
| AuthorizedOfficialFirstName: | FRANCISCO | ||||||||
| AuthorizedOfficialMiddleName: | LOPEZ | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6616307050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 120000652 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | ZZZ24685Z | 01 | CA | MEDICARE PART B | OTHER | PHA322610 | 05 | CA | MEDICAID | FHC70965F | 05 | CA | MEDICAID | HAP70965F | 01 | CA | FAMILY PACT | OTHER |