Provider Demographics
NPI:1871629733
Name:SAN PEDRO FAMILY CARE, PLC
Entity Type:Organization
Organization Name:SAN PEDRO FAMILY CARE, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-586-3664
Mailing Address - Street 1:890 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BENSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85602-6437
Mailing Address - Country:US
Mailing Address - Phone:520-586-3664
Mailing Address - Fax:520-586-3665
Practice Address - Street 1:890 W 4TH ST
Practice Address - Street 2:
Practice Address - City:BENSON
Practice Address - State:AZ
Practice Address - Zip Code:85602-6437
Practice Address - Country:US
Practice Address - Phone:520-586-3664
Practice Address - Fax:520-586-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ23688Medicare PIN