=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649658683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILKES FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2015
-----------------------------------------------------
Last Update Date | 05/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 S REINO RD SUITE 200
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-4284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-499-4446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 S REINO RD SUITE 200
-----------------------------------------------------
City | NEWBURY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-4284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-499-4446
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | DANNELLE MCDERMOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 805-499-4446
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | A85368
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | A85368
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------