Provider Demographics
NPI:1962516591
Name:TIMBERLAKE FAMILY PRACTICE, A MEDICAL CORP.
Entity type:Organization
Organization Name:TIMBERLAKE FAMILY PRACTICE, A MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-691-5855
Mailing Address - Street 1:9381 E STOCKTON BLVD STE 216
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-5070
Mailing Address - Country:US
Mailing Address - Phone:916-691-5855
Mailing Address - Fax:916-691-6066
Practice Address - Street 1:9381 E STOCKTON BLVD STE 216
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-5070
Practice Address - Country:US
Practice Address - Phone:916-691-5855
Practice Address - Fax:916-691-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA222025702Medicaid