Provider Demographics
NPI:1265751911
Name:FAMILY WELLCARE CORP
Entity type:Organization
Organization Name:FAMILY WELLCARE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-867-8278
Mailing Address - Street 1:9420 E GOLF LINKS RD
Mailing Address - Street 2:#306
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85730-1355
Mailing Address - Country:US
Mailing Address - Phone:520-867-8278
Mailing Address - Fax:
Practice Address - Street 1:9420 E GOLF LINKS RD
Practice Address - Street 2:#306
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730-1355
Practice Address - Country:US
Practice Address - Phone:520-867-8278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ138115Medicare PIN