MEDICARE: THE VILLAGE FAMILY DOCTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	A77911	CA

General Provider Information

NPI Number	:	1235443342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE VILLAGE FAMILY DOCTOR

Provider Business Mailing Address
First Line	:	207 BRIDGE ST
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-3311
Country	:	US
Telephone Number	:	805-481-1975
Fax Number	:	866-481-4145

Provider Business Practice Location Address
First Line	:	207 BRIDGE ST
Second Line	:
City	:	ARROYO GRANDE
State	:	CA
Zip	:	93420-3311
Country	:	US
Telephone Number	:	805-481-1975
Fax Number	:	866-481-4145

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KARIN YOUNG
Credential	:	M.D.
Telephone Number	:	805-481-1975

Provider Enumeration Date	:	07/30/2010
Last Update Date	:	07/30/2010

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