Basic Information
| Provider Information | |||||||||
| NPI: | 1255446464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOLINA HEALTHCARE OF CALIFORNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE STE 100 | ||||||||
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| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7777 SUNRISE BLVD STE 2500 | ||||||||
| Address2: | |||||||||
| City: | CITRUS HEIGHTS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956102372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167222227 | ||||||||
| FaxNumber: | 8778605422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| 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 | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR004265S | 05 | CA | MEDICAID |