Provider Demographics
NPI:1932322351
Name:FAMILY MEDICINE MARY CHAU DO INC
Entity Type:Organization
Organization Name:FAMILY MEDICINE MARY CHAU DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHAU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:951-301-6366
Mailing Address - Street 1:28125 BRADLEY RD
Mailing Address - Street 2:SUITE 240B
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-2248
Mailing Address - Country:US
Mailing Address - Phone:951-301-6366
Mailing Address - Fax:951-301-4336
Practice Address - Street 1:28125 BRADLEY RD
Practice Address - Street 2:SUITE 240B
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-2248
Practice Address - Country:US
Practice Address - Phone:951-301-6366
Practice Address - Fax:951-301-4336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7618261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH51103Medicare UPIN