Basic Information
| Provider Information | |||||||||
| NPI: | 1184738569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLINA HEALTHCARE OF CALIFORNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | #100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 5624996171 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908065502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624370373 | ||||||||
| FaxNumber: | 8774693631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 12/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | SCHUEREN | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | V.P. FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8885625442 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR004265A | 05 | CA | MEDICAID |