Basic Information
| Provider Information | |||||||||
| NPI: | 1629103890 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANTA CLARA VALLEY MEDICAL GROUP INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2705 LOMA VISTA RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930031581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672801 | ||||||||
| FaxNumber: | 8056672865 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 N BRENT ST | ||||||||
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| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930032809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056525011 | ||||||||
| FaxNumber: | 8056672865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOMINGUEZ | ||||||||
| AuthorizedOfficialFirstName: | VICTOR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8055259595 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A55866 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0103120 | 01 | CA | MEDI-CAL | OTHER |