Provider Demographics
NPI:1558395509
Name:CREEKSIDE OSTEOPATHIC FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:CREEKSIDE OSTEOPATHIC FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:916-984-4100
Mailing Address - Street 1:1731 CREEKSIDE DR
Mailing Address - Street 2:#100
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-984-4100
Mailing Address - Fax:916-984-4154
Practice Address - Street 1:1731 CREEKSIDE DR
Practice Address - Street 2:#100
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630
Practice Address - Country:US
Practice Address - Phone:916-984-4100
Practice Address - Fax:916-984-4154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5262207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE25102Medicare UPIN