Basic Information
| Provider Information | |||||||||
| NPI: | 1871629733 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN PEDRO FAMILY CARE, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 890 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856026437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205863664 | ||||||||
| FaxNumber: | 5205863665 | ||||||||
| Practice Location | |||||||||
| Address1: | 890 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856026437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205863664 | ||||||||
| FaxNumber: | 5205863665 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | WILEY | ||||||||
| AuthorizedOfficialFirstName: | JANINE | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5205863664 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.