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General NPI Number Information
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NPI Number | 1629372073
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Entity Type | Organization
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Legal Business Name | FOLSOM FAMILY AND SPORTS MEDICAL GROUP INC.
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Dates
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Enumeration Date | 12/28/2010
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Last Update Date | 12/31/2024
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Provider Practice Location Address
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Address Line | 2545 E BIDWELL ST STE 110
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City | FOLSOM
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State | CA
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Zip | 95630-6443
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Country | US
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Telephone | 916-941-7362
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Fax | 866-779-3899
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Provider Business Mailing Address
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Address Line | 2545 E BIDWELL ST STE 110
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City | FOLSOM
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State | CA
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Zip | 95630-6443
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Country | US
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Telephone | 916-941-7362
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Fax | 866-779-3899
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Authorized Official
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Title or Position | MANAGER
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Name | MELANIE MILLER
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Credential |
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Telephone | 916-365-3431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A64163
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License Number State | CA
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