Healthcare Provider Details

I. General information

NPI: 1871629733
Provider Name (Legal Business Name): SAN PEDRO FAMILY CARE, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 W 4TH ST
BENSON AZ
85602-6437
US

IV. Provider business mailing address

890 W 4TH ST
BENSON AZ
85602-6437
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-3664
  • Fax: 520-586-3665
Mailing address:
  • Phone: 520-586-3664
  • Fax: 520-586-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JANINE F WILEY
Title or Position: MANAGER
Credential:
Phone: 520-586-3664