Healthcare Provider Details

I. General information

NPI: 1245280718
Provider Name (Legal Business Name): FAMILY HEALTH CENTRE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 W LINE ST
BISHOP CA
93514-3315
US

IV. Provider business mailing address

686 W LINE ST
BISHOP CA
93514-3315
US

V. Phone/Fax

Practice location:
  • Phone: 760-872-4311
  • Fax: 760-872-4130
Mailing address:
  • Phone: 760-872-4311
  • Fax: 760-872-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC371720
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA93866
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberY201575
License Number StateCA

VIII. Authorized Official

Name: MRS. VASUKI SUE SITTAMPALAM
Title or Position: OWNER
Credential: M.D.
Phone: 760-872-4311