Provider Demographics
NPI:1215960091
Name:FULL CARE MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:FULL CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHONSARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-755-1255
Mailing Address - Street 1:3903 LONE TREE WAY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6249
Mailing Address - Country:US
Mailing Address - Phone:925-755-1255
Mailing Address - Fax:925-755-1259
Practice Address - Street 1:3903 LONE TREE WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6249
Practice Address - Country:US
Practice Address - Phone:925-755-1255
Practice Address - Fax:925-755-1259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty