Provider Demographics
NPI:1528106887
Name:VALLEY CENTER FAMILY PRACTICE MEDICAL GROUP INC
Entity type:Organization
Organization Name:VALLEY CENTER FAMILY PRACTICE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-749-0824
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:28743 VALLEY CENTER ROAD, SUITE B
Mailing Address - City:VALLEY CENTER
Mailing Address - State:CA
Mailing Address - Zip Code:92082-0348
Mailing Address - Country:US
Mailing Address - Phone:760-749-0824
Mailing Address - Fax:760-749-2189
Practice Address - Street 1:28743 VALLEY CENTER RD
Practice Address - Street 2:SUITE B
Practice Address - City:VALLEY CENTER
Practice Address - State:CA
Practice Address - Zip Code:92082-6530
Practice Address - Country:US
Practice Address - Phone:760-749-0824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW6430Medicare ID - Type Unspecified