1790795623 NPI number — MARINA FAMILY MEDICAL GROUP, INC.

Table of content: (NPI 1790795623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790795623 NPI number — MARINA FAMILY MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARINA FAMILY MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790795623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 90426
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90809-0426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-421-0122
Provider Business Mailing Address Fax Number:
562-421-2335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5888 EDINGER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92649-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-377-7469
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GROVE
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
714-377-7469

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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