1215107354 NPI number — ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215107354 NPI number — ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOPAEDIC MEDICAL GROUP OF RIVERSIDE, 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:
1215107354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6850 BROCKTON AVE
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
RIVERSIDE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92506-3808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-774-4611
Provider Business Mailing Address Fax Number:
951-276-3597

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6850 BROCKTON AVE
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
RIVERSIDE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92506-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-774-4611
Provider Business Practice Location Address Fax Number:
951-276-3597
Provider Enumeration Date:
03/05/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUAJARDO
Authorized Official First Name:
JUAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
951-774-4611

Provider Taxonomy Codes

  • Taxonomy code: 103TC1900X , with the licence number:  PSY 11922 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2081P2900X , with the licence number: A69385 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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