Basic Information
| Provider Information | |||||||||
| NPI: | 1073669404 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CANYON SPRINGS MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26520 CACTUS AVE | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865610 | ||||||||
| FaxNumber: | 9514865620 | ||||||||
| Practice Location | |||||||||
| Address1: | 26520 CACTUS AVE RM B2018 | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925553927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514865610 | ||||||||
| FaxNumber: | 9514865620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 04/23/2018 | ||||||||
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| AuthorizedOfficialLastName: | JUKAKU | ||||||||
| AuthorizedOfficialFirstName: | FAHEEM | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9514865610 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0088740 | 05 | CA | MEDICAID |