Healthcare Provider Details

I. General information

NPI: 1851830699
Provider Name (Legal Business Name): PRIMARY CARE FAMILY PRACTICE APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 11/13/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 BROCKTON AVE STE 200
RIVERSIDE CA
92506-3818
US

IV. Provider business mailing address

6900 BROCKTON AVE STE 200
RIVERSIDE CA
92506-3818
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-6263
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC53604
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMER SANNOUFI
Title or Position: OWNER
Credential: MD
Phone: 951-682-6263