Provider Demographics
NPI:1669593398
Name:ESTRELLA FAMILY MEDICAL, LLC.
Entity type:Organization
Organization Name:ESTRELLA FAMILY MEDICAL, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:623-298-4642
Mailing Address - Street 1:750 N ESTRELLA PKWY
Mailing Address - Street 2:SUITE 20
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9272
Mailing Address - Country:US
Mailing Address - Phone:623-298-4642
Mailing Address - Fax:623-925-9193
Practice Address - Street 1:750 N. ESTRELLA PARKWAY
Practice Address - Street 2:SUITE 20
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338
Practice Address - Country:US
Practice Address - Phone:623-298-4642
Practice Address - Fax:623-925-9193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ115319Medicare PIN