=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316412729
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE PHYSICIANS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2018
-----------------------------------------------------
Last Update Date | 10/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4201 WILSHIRE BLVD STE 334
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-462-4899
-----------------------------------------------------
Fax | 818-356-4380
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4201 WILSHIRE BLVD STE 334
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90010-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-462-4899
-----------------------------------------------------
Fax | 818-356-4380
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | DAISY I BAUTISTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 818-462-4899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------