Healthcare Provider Details

I. General information

NPI: 1871487199
Provider Name (Legal Business Name): FAMILY PRIMARY AND SPECIALTY CARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 W AVENUE Q STE B
PALMDALE CA
93551-3892
US

IV. Provider business mailing address

PO BOX 16297
BEVERLY HILLS CA
90209-2297
US

V. Phone/Fax

Practice location:
  • Phone: 661-425-0295
  • Fax:
Mailing address:
  • Phone: 661-425-0295
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERTO SANTANA
Title or Position: TREASURER
Credential:
Phone: 661-425-0295