Provider Demographics
NPI:1780120220
Name:FAMILY HEALTH MEDICAL CENTER INC.
Entity type:Organization
Organization Name:FAMILY HEALTH MEDICAL CENTER INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWTHORNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-827-4747
Mailing Address - Street 1:1045 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-4204
Mailing Address - Country:US
Mailing Address - Phone:209-827-4747
Mailing Address - Fax:209-827-5831
Practice Address - Street 1:444 SANTA RITA AVENUE
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-4204
Practice Address - Country:US
Practice Address - Phone:209-827-4747
Practice Address - Fax:209-827-5831
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAMILY HEALTH MEDICAL CENTER INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-09
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61093261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA61093OtherMD LICENSE