Healthcare Provider Details

I. General information

NPI: 1780081141
Provider Name (Legal Business Name): WELLFLEET FAMILY MEDICAL INC A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N MOUNTAIN AVE SUITE A-100
UPLAND CA
91786-4359
US

IV. Provider business mailing address

600 N MOUNTAIN AVE SUITE A-100
UPLAND CA
91786-4359
US

V. Phone/Fax

Practice location:
  • Phone: 909-938-2681
  • Fax:
Mailing address:
  • Phone: 909-938-2681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANNETTE M HOLLENBECK
Title or Position: PRESIDENT
Credential: FNP
Phone: 909-938-2681