=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093010159
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAGUNA FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2011
-----------------------------------------------------
Last Update Date | 01/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9281 OFFICE PARK CIR SUITE 120
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95758-8068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-691-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9281 OFFICE PARK CIRCLE SUITE 120
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-691-4300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. GLENDA GOODWIN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 916-691-4300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | A71660
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------