Healthcare Provider Details

I. General information

NPI: 1285609792
Provider Name (Legal Business Name): ORANGEVALE FAMILY MEDICAL CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8864 GREENBACK LN SUITE B
ORANGEVALE CA
95662-4050
US

IV. Provider business mailing address

8864 GREENBACK LN SUITE B
ORANGEVALE CA
95662-4050
US

V. Phone/Fax

Practice location:
  • Phone: 916-988-2900
  • Fax: 916-988-2990
Mailing address:
  • Phone: 916-988-2900
  • Fax: 916-988-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5262
License Number StateCA

VIII. Authorized Official

Name: MS. CHRISTINE WILSON
Title or Position: PRESIDENT OFFICE MANAGER
Credential: PA-C
Phone: 916-988-2900