=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245280718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY HEALTH CENTRE MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/12/2006
-----------------------------------------------------
Last Update Date | 04/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 686 W LINE ST
-----------------------------------------------------
City | BISHOP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93514-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-872-4311
-----------------------------------------------------
Fax | 760-872-4130
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 686 W LINE ST
-----------------------------------------------------
City | BISHOP
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93514-3315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-872-4311
-----------------------------------------------------
Fax | 760-872-4130
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. VASUKI SUE SITTAMPALAM
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 760-872-4311
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | C371720
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | Y201575
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A93866
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------