Healthcare Provider Details

I. General information

NPI: 1629372073
Provider Name (Legal Business Name): FOLSOM FAMILY AND SPORTS MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2010
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 E BIDWELL ST STE 110
FOLSOM CA
95630-6443
US

IV. Provider business mailing address

2545 E BIDWELL ST STE 110
FOLSOM CA
95630-6443
US

V. Phone/Fax

Practice location:
  • Phone: 916-941-7362
  • Fax: 866-779-3899
Mailing address:
  • Phone: 916-941-7362
  • Fax: 866-779-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA64163
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELANIE MILLER
Title or Position: MANAGER
Credential:
Phone: 916-365-3431