Healthcare Provider Details

I. General information

NPI: 1831170745
Provider Name (Legal Business Name): PEACHWOOD MEDICAL GROUP CLOVIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W HERNDON AVE
CLOVIS CA
93612-0204
US

IV. Provider business mailing address

275 W HERNDON AVE
CLOVIS CA
93612-0204
US

V. Phone/Fax

Practice location:
  • Phone: 559-324-6200
  • Fax: 559-324-6280
Mailing address:
  • Phone: 559-324-6200
  • Fax: 559-324-6280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. LEE ROY COPELAND
Title or Position: PRESIDENT
Credential: M.D.
Phone: 559-324-6200