Provider Demographics
NPI:1629372073
Name:FOLSOM FAMILY AND SPORTS MEDICAL GROUP INC.
Entity Type:Organization
Organization Name:FOLSOM FAMILY AND SPORTS MEDICAL GROUP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-365-3431
Mailing Address - Street 1:4989 GOLDEN FOOTHILL PKWY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-9639
Mailing Address - Country:US
Mailing Address - Phone:916-941-7362
Mailing Address - Fax:866-779-3899
Practice Address - Street 1:4989 GOLDEN FOOTHILL PKWY
Practice Address - Street 2:SUITE 5
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-9639
Practice Address - Country:US
Practice Address - Phone:916-941-7362
Practice Address - Fax:866-779-3899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64163207Q00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty