Basic Information
| Provider Information | |||||||||
| NPI: | 1588972806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST MARY SPECIALTY CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT LA 21190 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911851190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144494800 | ||||||||
| FaxNumber: | 7144494956 | ||||||||
| Practice Location | |||||||||
| Address1: | 19333 BEAR VALLEY RD STE 106 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923085149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602405505 | ||||||||
| FaxNumber: | 7602405525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 05/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | MUKAI | ||||||||
| AuthorizedOfficialFirstName: | MOSES | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7144494800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.