Basic Information
| Provider Information | |||||||||
| NPI: | 1619218542 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FIRST CARE MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | FIRST CARE MEDICAL GROUP- LYNDHURST | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5626 OBERLIN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211705 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 VALLEY BROOK AVE | ||||||||
| Address2: | |||||||||
| City: | LYNDHURST | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070711301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018960900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2013 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OPS | ||||||||
| AuthorizedOfficialTelephone: | 8589641506 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 25MA04732500 | NJ | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.