Basic Information
| Provider Information | |||||||||
| NPI: | 1457300436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MISSION SURGICAL CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2828 | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928782828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512788870 | ||||||||
| FaxNumber: | 9512788913 | ||||||||
| Practice Location | |||||||||
| Address1: | 7300 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925043849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512788870 | ||||||||
| FaxNumber: | 9512788913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | CHIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9512788870 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 20A10803 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | G75730 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 20A9434 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 363AS0400X | PA16804 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 208600000X | G56529 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G565290 | 05 | CA | MEDICAID |