Provider Demographics
NPI:1700027661
Name:FAMILY PRACTICE MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:FAMILY PRACTICE MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-331-7369
Mailing Address - Street 1:PO BOX 801463
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91380-1463
Mailing Address - Country:US
Mailing Address - Phone:661-295-0859
Mailing Address - Fax:661-295-0862
Practice Address - Street 1:274 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1906
Practice Address - Country:US
Practice Address - Phone:626-331-7369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25707207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA25707OtherSTATE LICENSE OF PRESIDENT