Provider Demographics
NPI:1447524921
Name:PROMEDICAL FAMILY PRATICE
Entity type:Organization
Organization Name:PROMEDICAL FAMILY PRATICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMENISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAUDE
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:707-407-0540
Mailing Address - Street 1:815 7TH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-1113
Mailing Address - Country:US
Mailing Address - Phone:707-407-0540
Mailing Address - Fax:707-268-5573
Practice Address - Street 1:815 7TH ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1113
Practice Address - Country:US
Practice Address - Phone:707-407-0540
Practice Address - Fax:707-268-5573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86543261QH0100X
CA16089261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service