Provider Demographics
NPI:1063815165
Name:LIFE FAMILY MEDICINE CLINIC, INC
Entity Type:Organization
Organization Name:LIFE FAMILY MEDICINE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAJORITY OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SOU
Authorized Official - Middle Name:
Authorized Official - Last Name:HER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:916-706-1458
Mailing Address - Street 1:7275 E SOUTHGATE DR
Mailing Address - Street 2:STE 102
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7275 E SOUTHGATE DR
Practice Address - Street 2:STE 102
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2628
Practice Address - Country:US
Practice Address - Phone:916-704-1458
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28085111N00000X
CA20A11874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty