Provider Demographics
NPI:1659539906
Name:ACACIA FAMILY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ACACIA FAMILY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMANA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:931-663-9500
Mailing Address - Street 1:8020 SAN MIGUEL CANYON RD
Mailing Address - Street 2:
Mailing Address - City:PRUNEDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93907-1208
Mailing Address - Country:US
Mailing Address - Phone:831-663-9500
Mailing Address - Fax:831-663-9503
Practice Address - Street 1:8036 SAN MIGUEL CANYON RD
Practice Address - Street 2:
Practice Address - City:PRUNEDALE
Practice Address - State:CA
Practice Address - Zip Code:93907-1208
Practice Address - Country:US
Practice Address - Phone:831-663-0123
Practice Address - Fax:831-663-9503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083011Medicaid