Provider Demographics
NPI:1942682596
Name:PRIME FAMILY CLINIC INC
Entity Type:Organization
Organization Name:PRIME FAMILY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:E
Authorized Official - Last Name:ESPINOSA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-945-5502
Mailing Address - Street 1:1110 S GLENDALE AVE
Mailing Address - Street 2:E
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-5617
Mailing Address - Country:US
Mailing Address - Phone:818-945-5502
Mailing Address - Fax:818-945-5595
Practice Address - Street 1:1110 S GLENDALE AVE
Practice Address - Street 2:E
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-5617
Practice Address - Country:US
Practice Address - Phone:818-945-5502
Practice Address - Fax:818-945-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23122208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23122Medicare Oscar/Certification