Provider Demographics
NPI:1427417559
Name:TIMBERLAKE FAMILY PRACTICE A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TIMBERLAKE FAMILY PRACTICE A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-691-5855
Mailing Address - Street 1:8120 TIMBERLAKE WAY
Mailing Address - Street 2:#207
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5412
Mailing Address - Country:US
Mailing Address - Phone:916-691-5855
Mailing Address - Fax:916-691-6066
Practice Address - Street 1:8120 TIMBERLAKE WAY
Practice Address - Street 2:#207
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5412
Practice Address - Country:US
Practice Address - Phone:916-691-5855
Practice Address - Fax:916-691-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care