Basic Information
| Provider Information | |||||||||
| NPI: | 1396085569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RELEVARE GROUP INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1770 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919441770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194641165 | ||||||||
| FaxNumber: | 6195671011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1287 FULTON RD | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078885808 | ||||||||
| FaxNumber: | 7075778315 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2013 | ||||||||
| LastUpdateDate: | 03/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | MEDVIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7078885808 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A0736012 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.