=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013314046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTHCARE OF CHOWCHILLA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2014
-----------------------------------------------------
Last Update Date | 01/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 ROBERTSON BLVD
-----------------------------------------------------
City | CHOWCHILLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93610-2633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-827-4747
-----------------------------------------------------
Fax | 209-827-5831
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1045 5TH ST
-----------------------------------------------------
City | LOS BANOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93635-4204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-827-4747
-----------------------------------------------------
Fax | 209-827-5831
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYCIAN
-----------------------------------------------------
Name | PEDRO R FEBRES-ROMAN
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 209-827-4747
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | A29593
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------