Healthcare Provider Details

I. General information

NPI: 1700027661
Provider Name (Legal Business Name): FAMILY PRACTICE MEDICAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 W BADILLO ST
COVINA CA
91723-1906
US

IV. Provider business mailing address

PO BOX 801463
SANTA CLARITA CA
91380-1463
US

V. Phone/Fax

Practice location:
  • Phone: 626-331-7369
  • Fax:
Mailing address:
  • Phone: 661-295-0859
  • Fax: 661-295-0862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA25707
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA25707
License Number StateCA

VIII. Authorized Official

Name: DR. RANDOLPH BETTS
Title or Position: PRESIDENT
Credential:
Phone: 626-331-7369