Provider Demographics
NPI:1790798908
Name:ROCKLIN FAMILY PRACTICE AND SPORTS MEDICINE
Entity Type:Organization
Organization Name:ROCKLIN FAMILY PRACTICE AND SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROY
Authorized Official - Middle Name:MC
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-624-0300
Mailing Address - Street 1:3104 SUNSET BLVD
Mailing Address - Street 2:#2B
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677
Mailing Address - Country:US
Mailing Address - Phone:916-624-0300
Mailing Address - Fax:916-624-0631
Practice Address - Street 1:3104 SUNSET BLVD
Practice Address - Street 2:#2B
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677
Practice Address - Country:US
Practice Address - Phone:916-624-0300
Practice Address - Fax:916-624-0631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G639720Medicaid
CA0466260001Medicare NSC
CA00G639720Medicaid